There is, in this country, a great and solemn debate to be held on the merits of President Bill Clinton's plan for health-care reform. But if you fear that this debate might actually take place, and that you will have to suffer through tedious months of talk about utilization rates and micro-simulation models, relax.
The nation's medical fate will not be determined by the Clinton plan's complicated numbers. It will hang on not-so-complicated politics.
In recent years, Americans of all political stripes have complained about our health-insurance system, and we have been offered many solutions. Some say we should make every insurance firm cover a certain number of high-risk people, the way we do with auto insurance. The American left wants a Canadian-style system, with the government paying all bills. It might give us second-rate care, but at least it is comprehensible. Some conservatives want individuals to pay for their own care out of medical savings accounts, financed by tax breaks.
But the Clinton people, those self-proclaimed policy wonks, the ones who are supposed to be smart enough to make government work where others have failed, have gone for none of these.
Instead, the Clinton plan offers a combination of competition and ham-fisted regulation, a promise to simultaneously streamline and create scores of new bureaucracies, a design whose numbers no economist outside the White House will defend. The plan makes little policy sense. But it is a model of political logic.
For example, health experts agree we will never approximate a market in medical care until we stop subsidizing health benefits through tax breaks. The Clintonites know this. But the necessary tax changes are not there, because labor leaders reject them.
The Clinton plan, preaching responsibility, requires all businesses, big and small, to pay for workers' insurance. But small business is a dangerous group to have arrayed against you in a legislative fight, so the plan turns around and gives the money back to them, in the form of a government subsidy.
The Clinton Administration has declared war on pharmaceutical companies. But prescription drugs are where the elderly incur the biggest out-of-pocket medical costs. And senior citizens are even fiercer than small businessmen. So drugs are put under the government's insurance umbrella.
In fact, Clinton's entire approach to his health plan is a piece of impressively intelligent politics.
He has declared that once Congress gets his plan, he will insist on preserving only the Big Principles. On details, he'll be laid back. You want to phase it in more slowly? We'll negotiate. You recommend fiddling around with the benefits package? Let's talk.
Clinton has trumpeted his flexibility so loudly that he is clearly doing more than just building support. He is telling Congress and interest groups they can play a big role in the plan's design. Almost irrespective of what emerges from Congress, he can look at the baby, announce his parenthood and claim victory.
Moreover, if the dickering lasts long enough, the plan will be barely launched by the time Clinton runs for reelection in 1996. His ideas may prove to be a disaster, but the country will not yet know it.
The sales strategy for the Clinton plan is shaping up to be just as politically shrewd. It has three parts. In Part One, the Clintonites show an eager bipartisanship on the Hill. Hillary Rodham Clinton is doing yeoperson work in briefing the legislators. During the President's address to Congress, she made brilliant use of the Trophy Seats next to the First Lady in the House gallery, where the Clintons put highly symbolic persons who have been flattered into lending their presence to legitimize some proposal.
Hillary's companions were the pediatrician T. Berry Brazelton and--more important--C. Everett Koop, Ronald Reagan's surgeon general. Koop's anti-abortion position is anathema to many of the Clintons' closest supporters--but hey, business is business.
In Part Two, the Clintons run a conventional modern campaign for their plan. They are mobilizing their grass-roots allies in labor and the American Assn. of Retired Persons. They will visit Larry, Phil, Oprah and the morning talk shows. The day after the speech, the White House lawn was blanketed with Administration officials giving interviews on the plan. Their war room, which Hillary has renamed the delivery room, is as bouncing-off-the-walls as ever.
But if Parts One and Two have the Clintons and their helpers behaving like hyperactive pussycats, Part Three--the paid media campaign--is a matter of growls, snarls and bared teeth.
Granted, the insurance firms struck first. Knowing they were to be chief villains of the Clinton campaign, they started to run a TV commercial that showed a couple at their kitchen table discovering that the Clinton plan, despite its promises, had taken their freedom of medical choice away from them.
The ads aired before Clinton's speech to Congress. The Clinton folks were angry that the industry had "jumped the gun." (The rabbit, unsportsmanlike, had lit out for the hills before the hounds were ready.) So Clinton allies began running their own TV ads, bearing the message that if life-insurance companies were knocking the President's plan, it must be good for the people.
The Democratic National Committee has just sent me a glossy color flier with a note in it from the DNC and the President himself, offering me the "once-in-a-lifetime chance" to become an Official Health Care Volunteer. They will give me a Petition Volunteer Kit for collecting pro-Clinton-plan signatures from my neighbors. (These people clearly do not know my neighborhood.) The signatures will be used to help our congressmen resist "high-powered" pressure from the greedy interests opposed to the plan.
All I have to do to get the kit is to call an 800-number and fork over $15. They say they will take Visa or Mastercard.
That's what it will probably be like in the great health-care debate. We policy slaves will hold conferences about whether the Clinton plan is administrable. Meanwhile, in the real world, the fight will be about something else.
The post-Cold War world demands more competitiveness from this country. U.S. jobs and their attendant benefits are growing more unstable. Whatever employment-based welfare state we once had is breaking apart. The debate's outcome will hinge on how scared we are and how willing politicians are to exploit this fear. We will see how much we value freedom of choice; how much we yearn for security, and how much we mistrust the opposing institutions of government and the medical professions.
So, while the health-care fight may not devote sufficient attention to Clinton's problematic numbers, we should take heart: The debate will answer questions that are more important.