At the Stretch on Health Care--But What’s the Plan?

And now the really big question about health-care reform: Will the final legislation include Rita’s phone number?

As a congressional vote on health- care reform draws near, it is impor tant to keep Rita’s phone number in mind. In 1981, when the tax-cut plan proposed by Ronald Reagan was approaching its floor vote, the provisions of the bill were changing so frantically that members of Congress never saw a printed version of the bill before the final vote. Instead, they voted yea or nay on a sheaf of handwritten pages scrawled down by White House lobbyists. One page included the notation “CALL RITA,” with a phone number. This historic message was then dutifully transcribed into the U.S. Code of Federal Regulations. After all, it had been formally approved by Congress.

It turned out the legislators who voted on the 1981 tax-cut bill not only did not know that it contained Rita’s number, they barely understood any of the provisions: Chief among them that the law would create the mega-deficits that have plagued the federal government since.

This is the gathering dynamic on health-care reform. Hardly anyone can keep the provisions of the various “managed competition” proposals straight anymore. There exists considerable danger that when the House and Senate act to restructure the $900-billion health-care industry that, at about 14.5% of the gross national product, is larger than the auto and petroleum industries combined, many members of Congress will have only the faintest notion of what is in the bill.

Let’s see, there’s the Clinton plan, the Cooper plan, the Cooper-Breaux version of the Cooper plan, the Kennedy plan, the Moynihan plan, the Chafee plan and the Dole plan--to cite only the major proposals. These plans call for some version of voluntary mandated subsidized market-oriented standardized individual trigger-financed seasonally rotated regional alliances (with subsection D attainment zone waivers) for universal coverage (except for those not covered) beginning in the 1998-23rd Century time frame. The cost will be precisely approximately $25.95 to $500 billion, though we haven’t yet figured out if that is annually, or per person.

Not only are the provisions of the plans dimly understood: They are now changing so fast even policy wonks have difficulty remembering what stipulation is in which bill. After all those months of Hillary Rodham Clinton’s black-cloaked health-care monks coming to nuanced positions covering minute details, now in the rush to enact something, matters as fundamental as whether employers will be required to pay for health coverage, or only asked to pay, are being revised on an almost daily basis. New cost estimates are essentially being pulled out of the air.

To a certain extent, this is a predictable result of Clinton’s proposing a bill that, at 1,364 pages, was so complicated there was never a chance people would be able to keep its provisions straight. Then, when the first congressional opposition arose, White House officials began saying that everything was negotiable except for universal coverage. This meant open season.

Now, almost every major chairman of a relevant committee in the House and Senate has a reform bill--most cobbled-together admixtures of buzzwords and loopholes. An example is the “trigger” provision every bill suddenly seems to contain. Rather than an immediate requirement that employers provide health insurance, “trigger” provisions specify that if all Americans do not acquire health coverage five or 10 years down the road, employer mandates would be imposed. The “trigger” approach is a classic example of the political gimmick of taking credit for action today but postponing the hard work into the future.

Anyone remember the Gramm-Rudman bill? Enacted in 1985, it declared with great fanfare that, henceforth, Congress would be compelled to balance the budget--but postponed enactment of balanced budgets into future years. Gramm-Rudman allegedly had “trigger” provisions that future sessions of Congress would never be able to dodge. Every one was dodged.

Health-care trigger provisions appear to have about as much actuality as Gramm-Rudman. Since there is zero chance that universal coverage will achieve itself spontaneously, either an employer-mandate trigger would be “hard,” written in such a way as to be automatic, and thus would be a dishonest provision, shifting the accountability to a future Congress and White House; or the trigger would be “soft,” a Gramm-Rudman-style provision written so it can be easily circumvented.

That prominent Democrats such as Sen. Daniel Patrick Moynihan of New York are now speaking kindly of triggers, and Clinton has said he will consider them, indicates that serious health-care reform is in the process of evaporating. In fact, at this point it’s not even clear just what reform Clinton’s bill would achieve, let alone what would be achieved by any of the many watered-down alternatives.

Clinton’s plan, all major Democratic alternatives and the moderate Republican alternative backed by Sen. John H. Chafee of Rhode Island ought to be rechristened “insurance-reform” bills. All would outlaw the practice of health insurers barring coverage for those with pre-existing illnesses; make it easy for people who change jobs to change plans; make it easy for the self-employed to buy health insurance; impose some version of “community rating” where premiums are about the same for all who subscribe to the same plan, and require standardized insurance packages so that consumers could make meaningful price comparisons when they shop polices.

All these are valid reforms whose enactment will benefit consumers. Most are even reforms the health-insurance industry knows are needed, but that will only work if realized through uniform national legislation that keeps competition among individual companies equal.

Beyond that, it’s not clear what, if any, health-care reform will be accomplished. Clinton has repeatedly--and rightly--said the fact that the United States is the sole industrial nation without universal health care is an outrage, and that he would veto any bill that does not create universal health care. But his is the sole “managed competition” bill facing this issue head-on. Edward M. Kennedy’s plan waffles. The Cooper bill, authored by Rep. Jim Cooper (D-Tenn.), pointedly dodges universal coverage. Moynihan’s makes hazy promises about revisiting the issue in a decade or so.

Further on the non-reform front, Clinton’s mandatory regional health alliance requirement (whatever it means; no one has ever understood it) is teetering and may be withdrawn. Some of the plans now call instead for creation of health-purchasing cooperatives, but these sound hauntingly like existing HMOs and PPOs.

And the goal of containing health costs--the goal that most frightened the entrenched hospital, pharmaceutical and physician interests--has, to the pleasure of these groups, been forgotten in the ruckus. Cooper’s plan contains some non-binding mumbo-jumbo about how it would be nice if market forces drove down costs. Clinton’s plan is gradually being stripped of what meaningful cost-control measures it once had. The Kennedy, Moynihan, Chafee and other proposals barely mention cost controls.

If what ultimately passes Congress is health-insurance reform plus some vague language about purchasing co-ops, the aftermath for Clinton will be strange. Genuine good would be done by such a bill, particularly for the self-employed and those in the Kafkaesque position of being unable to obtain health insurance because they need it.

Health-insurance reform is a long overdue objective that neither Ronald Reagan nor George Bush would have touched with a 10-meter pole. Had the goal going in been health-insurance reform, Clinton would deserve praise for reaching it. But Clinton set for himself the high moral goal of universal coverage, and now may not attain it. This will enable pundits and Clinton’s opponents to portray the bill as a defeat.

Voters may end up thinking of the bill as a success for Clinton--because the insurance-reform aspects will be a boon to the middle class, particularly anyone who changes jobs or falls ill. Today middle-class complaints about health care turn not on costs or quality but on the problems of obtaining or keeping coverage. These will likely be solved by whatever bill Congress enacts.

To the extent that middle-class voters come to feel their health-care complaints have been resolved by Clinton’s actions, they will care less about the system’s two basic faults--the shameful lack of coverage for 15% of Americans, and the health-cost spiral that consumes ever more national wealth.

Meanwhile, the sole bill that does address both universal coverage and the need to control costs--the national-health or “single payer” legislation sponsored by Rep. Jim McDermott (D-Wash.)--now has 91 co-sponsors. This means that despite the continuous impression given in health-care commentary that no sentiment exists in U.S. politics for national health care, nearly a quarter of the House is now on record as favoring this approach.

British-style national health care would be a disaster. But France and Germany have national-health systems that provide universal coverage at a significantly lower percentage of GNP than the U.S. system, with no rationing, no waiting lines, hi-tech care and handsome incomes for doctors. These systems combine that best of market medicine--private practice physicians, privately administered insurance pools--with national cost controls. National health care can work. It will work someday in the United States: Maybe sooner than you think, especially if what is billed as sweeping health-care reform passes in 1994, but fails to address the system’s root problems of cost runaway and the uninsured.