Give the States a Crack at Devising Reform : Health policy: Congress is bogged down in politics and avoiding honest answers. Let’s look for regional solutions.
We have reached a point in the congressional struggle over health-care reform where there is enough opposition to defeat the Clinton Administration’s plan but nothing like a firm majority for an alternative. With proposals emerging from the House Ways and Means Committee, Senate Finance Committee and three other committees, the press reports are confusing, the policy issues are unintelligible to most Americans and the chances of deadlock are considerable.
Can a workable version of national reform be enacted when no majority exists for any single plan? The answer is yes, but you’d never know it from the compromise proposals now making the rounds. The real challenge for reformers is to find a strategy that reflects whatever agreement there is on the goals of health reform and accommodates the disagreements on means. Instead, in the search for a plan that can pass, the compromisers focus on what seems doable politically rather than what is substantively desirable.
Three of these political compromises--which look appealing on the surface but are badly thought through--currently crowd the agenda:
* Amending the definition of “universal coverage.” Debates on this issue mask a substantive disagreement about how great a role public compulsion, of either individuals or businesses, should play in ensuring coverage. A group in the Senate Finance Committee including John Chafee (R-R.I.) and John Breaux (D-La.) suggests giving up President Clinton’s nearly 100% goal and substituting a 95% coverage “target” by the 2002. This approach is misguided because it fails to confront either the large-scale insecurity or the cost escalation problems that have driven reform. Who will the 5% left uncovered turn out to be? You? Me? The chronically ill? The usually well? Only if we know the answers to these questions would we know whether reform was likely to achieve its major goals. The methods proposed to increase coverage if it falls below the target percentage may also be misaimed--either ineffective (another study of the problem) or pointed in the wrong direction (employer mandates, which would fizzle if the uninsured were not workers).
* A continuing aversion to straight talk about paying for reform. This was evident in President Clinton’s original proposal that employers pay for the health insurance of their employees, reinforcing the delusion that because employers write checks for health insurance, they bear the costs. Then and now, it is we citizens who bear the costs, whether it’s through direct taxes, increased prices or forgone wages and employment. The only relevant questions--then or now--concern the fairness and sustainability of the distribution of the costs. We will keep paying a steep price in confusion and discord until this crucial matter is understood. Those who want to avoid all mandates--individual or employer--have given us a scheme that is truly illusory: Tax 40% of the most expensive health-insurance plans to provide subsidies for low- and moderate-income Americans. But people in expensive plans may be there because they are ill, not because they are rich. And the game-playing that will go on by people trying to stay below the 60th percentile ought to reemploy any insurance company personnel laid off by other reforms.
* Forgetting about the cost-control problems that prompted the reform movement in the first place. The continuing escalation of health costs, which still threatens the affordability of health insurance, has dropped out of the vocabulary of compromise. Words like moderate or centrist typically appear in descriptions of senators like Breaux, Chafee, David Durenberger (R-Minn.), Kent Conrad (D-N.D.), David Boren (D-Okla.) and others, but they don’t fit the reforms sponsored by them, because they contain no serious approaches to cost control. Just as it does not make sense to cross a chasm in two steps rather than a leap, it is impossible to have workable health reform without slowing the rate of expenditure increases.
Is there a compromise that builds on agreed goals but permits enough variation of means to assemble a majority for reform? One possibility is state-led reform (in this, California is a leader, with its modified single-payer health-reform initiative on the November ballot). Congress could pass legislation that provided federal assistance to states that enacted universal coverage, insurance law reform and reasonable controls on costs. This would leave states free to choose which administrative and health-delivery changes they wanted to implement. By mandating basic reform principles without imposing their administration, state-led reform builds on the reformers’ consensus about goals while allowing for wide differences in the means of achieving them.
States already have a significant track record in health reform, including Hawaii’s near-universal coverage and employer mandates. Given the diversity of states, their varied experience with health care and intense local preferences, why enact a single brand of national health reform, especially if it’s the poorly considered compromise that we seem to be headed toward?
By moving compromise in the direction of preserving goals rather than defining means, we can allow states the further thought and experimentation that are needed for effective implementation.
