Enemy Is Bureaucrats, HMO or Feds

Remember the debate over health-care reform four years ago? It’s back. Actually, it never really went away. Just as many people think the health-care system is in crisis now--about 40%, according to last week’s Gallup poll--as thought that in 1994.

Four years ago, the crisis was driven by people’s fear of losing their health insurance if they lost their jobs. Today, people’s jobs are more secure. So what’s driving this crisis? Essentially, the same thing as in 1994: fear of bureaucratic rationing. But this time, the bureaucrats are private, not public.

Most Americans don’t see much of a difference. But it makes a big difference politically. Now Republicans have to worry about being in the same unhappy position Democrats were in four years ago, namely, defending bureaucratic intrusion in the health-care system.

There’s one big difference between 1994 and 1998: Most Americans are now in managed-care plans. They’re worried about their rights. The biggest applause line in President Bill Clinton’s State of the Union speech in January came when he said, “I urge this Congress to reach across the aisle and write into law a consumer bill of rights that says this: You have the right to know all your medical options, not just the cheapest. You have the right to choose the doctor you want for the care you need.”

Are people in managed care unhappy with the quality of their medical care? Actually, no. Seven of eight told Gallup they were satisfied. Not very satisfied, mind you. Just 39% said that, compared with 59% of people in traditional fee-for-service plans, where there are no restrictions on choice.

Why the difference? Most people in managed care have not had bad experiences, like having their insurance company overrule their doctor. Fourteen percent of people in managed care say that’s happened to them or to someone in their family. That compares with 9% of people in traditional plans. Have they been denied medical treatment they thought was necessary? That has happened to 12% of people in managed care and 7% of people in traditional plans.

Do people in managed care want to change to another type of plan? Most say “no.” Would they recommend their health-care plan to someone else? More than two-thirds say “yes.” Nonetheless, people in both kinds of plans agree: A fee-for-service plan in which you can go to any doctor you choose is better than a managed-care plan.

Remember the scene in the movie “As Good As It Gets,” when the mother with the asthmatic son complains to a private physician about her son not getting the proper medical tests: “Those *#!*# HMO bastards! They said they weren’t covered under my plan and weren’t necessary!” When she apologizes for her language, the physician responds, “That’s all right. I think that’s actually their technical name.” Audiences all over the country applauded.

What’s creating public anxiety is the basic concept of managed care: that a bureaucrat can control your health care. As Democratic pollster Mark Mellman put it, “The public sees somebody 2,500 miles away in some insurance company or health-care plan, sitting behind a computer terminal, telling their doctor what treatments and tests that doctor can use, what medicines the doctor can prescribe, and the public says, ‘Enough of that.’ ”

Americans don’t like bureaucratic rationing. That’s why gasoline lines were such a bitter experience in the 1970s. In this country, it’s much easier to ration things by price. When people were told they had to wait in line for gasoline, or fill up only on odd or even days, or leave their cars at home certain days, we almost had a revolution. How did the problem get solved? The price of gasoline went up. Sure, people complained about having to pay a dollar a gallon for gas. But it was better than waiting in line.

Health care has always been rationed by price, too. If you have more money, you can buy better care. Do Americans think that’s fair? Of course not. In fact, 69% believe the federal government should guarantee health care for all Americans, about the same as in 1994. But when the Clinton administration tried to turn that view into a mandate for health-care reform, the public balked. They were afraid Hillary Rodham Clinton’s 1,510-page health-care plan would give the government too much control.

Americans didn’t want government bureaucrats to come between them and their doctors. That is, of course, exactly what happens with Medicare, the most popular government program after Social Security. But for most Americans younger than 65, government rationing of health care is frightening and unfamiliar. The Health Insurance Assn. of America saw to that by running the “Harry and Louise” ads.

Well, guess what? The same fears have materialized again. Only this time, they’re targeted at insurance companies. Democrats are running ads echoing Clinton’s State of the Union message. Like this one, in North Carolina: “John Edwards, running for the Senate on the people’s platform. A patients’ bill of rights so insurance companies can’t stop you from choosing your own doctor.” Or this, in a Texas congressional race: “Tired of visiting the doctor and finding out you really have an appointment with . . . an accountant? Parents don’t deserve accountants and bureaucrats making medical decisions that fail to meet their needs.”

Republicans initially denounced Democratic reform proposals as more big-government meddling. Many believed the current crisis would pass with time, as Americans became more comfortable with managed care. Isn’t that what happened with Medicare? All the GOP had to do was keep Congress from taking rash action.

Then GOP congressmen started hearing from constituents. They began to worry. They worried about polls showing that Clinton is trusted more than the GOP in Congress on health-care issues. They worried that being seen as defenders of the insurance industry could be just as damaging for Republicans as it was for Democrats to be seen as defenders of big government four years ago.

Most of all, they worried that the health-care issue could tip the scales in the Democrats’ favor in this year’s midterm elections. House Republicans started signing on to a bipartisan anti-HMO bill that did not have the blessing of the House GOP leadership. Speaker Newt Gingrich (R-Ga.) saw the threat and appointed a task force to come up with a Republican reform bill. Two weeks ago, they did.

The GOP proposal does not go as far as the Democratic plan in establishing protection for consumers. For example, the GOP plan does not guarantee patients access to specialists outside their HMO network. It does not guarantee patients the right to sue their HMOs. Republicans say the Democratic plan would produce more litigation, higher costs and immense new bureaucratic authority for the federal government to regulate health care.

Democrats insist the GOP isn’t really interested in reform. They’re just looking for political cover. House Minority Leader Richard A. Gephardt (D-Mo.) insisted, “The Republican proposal is designed for show, not to become law.” But the health-insurance industry proceeded to do the GOP a big favor. They denounced the GOP proposal--and gave it legitimacy.

Republicans claim they can regulate the abuse of power by HMO’s without giving more power to government. Rep. J. Dennis Hastert (R-Ill.), chairman of the GOP task force, introduced his party’s proposal last month by saying, “I’m proud that our plan provides patients with the necessary protections to get them well without new taxes, more bureaucracy or the heavy hand of government.”

It’s an argument that has worked for Republicans before. Twice, in fact. First, when they defeated Clinton’s health-care bill in 1994. Again this year, on the tobacco bill. Both times, Democrats fell into the trap of pushing for too much government. That was the message of the TV-ad campaigns run by the health-insurance industry in 1994 and the tobacco industry this year. In both cases, the ads worked by creating fear of the unknown.

But this time, there’s a new element in the equation: fear of the known, namely, concern that insurance companies already have too much power. Republicans can’t get away with just killing the Democrats’ proposal. They have to pass a credible plan of their own. The bottom line is that the U.S. public doesn’t want to give too much power to any bureaucrats. It doesn’t matter whether they work for the federal government or for the insurance industry.