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Managed Care Eludes Only Congress : Health: Washington should pay attention to reforms occurring at the grass-roots level.

<i> Irene Wielawski is a former reporter for The Times who is following health-care reform under a Robert Wood Johnson Foundation grant. </i>

News of the death of health reform is greatly exaggerated. By failing to enact legislation this term, Congress has certainly removed itself as a focal point in the debate. But to say that spells the end of reform is to ignore what has been happening in hospitals, doctors’ offices, work-places and state legislatures while Capitol Hill held the spotlight.

Millions of Americans are already experiencing what President Clinton’s health security plan would have imposed by government fiat--managed care. Projections show that by the end of this year, as much as 60% of the privately insured work force will be in managed care programs, compared with about 33% in 1986.

That is a stunning turnaround, affecting just about every aspect of health care, from the doctor-patient relationship to economic incentives for research and new technology to the halls of academe. In a managed care world, there’s no place for medical schools that continue to turn out specialists in the volume that so badly skewed the nation’s physician supply. And, while questions remain about managed care’s ability to deliver what it promises--quality at a lower price--there is no denying that the experiment is well under way without any assist from Washington.

Consider what states have done while eyes, ears and headlines were riveted on Washington’s attempt to craft a single solution for the nation. Since President Clinton unveiled his plan a year ago, 40 states have passed 99 laws implementing elements of the Administration’s proposal and competing alternatives. Arizona, for example, amended its tax code to permit individual medical savings accounts, 19 states reformed insurance laws and 20 paved the way for group purchasing cooperatives. In California, voters will weigh in this November on a proposed single-payer insurance system.

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The fact is, health reform didn’t begin with the 1992 presidential campaign, and it won’t end because Congress failed to act this term.

It’s hard to stay enthusiastic about Washington’s version of reform when the issue that brought so many people together--the suffering of 37 million Americans who can’t afford insurance or medical care--is buried in partisan bickering. But that doesn’t mean people no longer care about the plight of the uninsured, or that middle-class Americans no longer worry that job loss or personal catastrophe might add them to the count.

In fact, some of the most interesting reform experiments are reaching out to precisely these outcasts. They are mostly community-based efforts, and none presume to have the answer for all 37 million. But in the modesty of their goals may lie wisdom that eluded the brilliant theorists of top-down reform. The sheer variety of approaches in these grass-roots efforts makes them excellent laboratories for testing reform theories before committing billions from the national Treasury. The variety also suggests that local communities may better grasp the subtleties of why certain people don’t get health care.

Sacramento is one such proving ground. There, the county health department has teamed up with the medical school at UC Davis, the local medical society and several private hospitals to bring health services to poor people living downtown. Yet, even in this middle-sized city with two relatively small, underserved neighborhoods, the organizers found two distinct neighborhoods, each requiring a different approach.

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One neighborhood contains an older, mostly homeless population in need of specialized care for heart disease, arthritis and other problems that beset people as they age. The other neighborhood is teeming with young immigrant families; prenatal, pediatric, immunization and family planning services top the list of needs, as well as clinic staff conversant in Hmong and Vietnamese.

Can these projects reach their goals within the existing health care framework? Time will tell. They will certainly help inform the next round of debate in Congress. And it may yield a blueprint for national reform that rings truer to what Americans already are experiencing than the proposals killed on Capitol Hill.


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