Strong medicine
Health care reform is back in the news. This time, does it stand a chance?
By Jonathan Cohn, 12/1/2002
WHEN SENATOR EDWARD Kennedy announced on Nov. 21 that he would soon propose a plan for universal health insurance, it barely qualified as news. Kennedy has been a member of Congress for 40 years now, and in that time he's introduced major health care bills at least a dozen, maybe two dozen times. But for once, Kennedy's timing seemed exquisite. In the past, the senator has been a lonely champion of health care reform, fighting not only Republicans but even more cautious members of his own party. This time around, Kennedy has company in his crusade. And lots of it.
Just days before Kennedy made his announcement, Al Gore surprised reporters with his announcement that he will call for the creation of a ''single-payer'' health insurance system in the United States - that is, a system in which the government provides every citizen with health insurance directly, just as it does in Canada. Almost immediately, two of Gore's would-be rivals for the 2004 Democratic presidential nomination, Senators John Edwards and John Kerry, indicated they'd soon be unveiling health care plans of their own. Assuming all three men make good on their promises, they'll be following the lead of a fourth Democratic presidential contender, Vermont Governor Howard Dean, who long ago made universal health insurance the centerpiece of his upstart candidacy.
And Democrats running for president aren't the only ones talking about big changes in health care. The National Academy of Sciences has placed a starkly worded report on the desk of President Bush. ''The American health care system is confronting a crisis,'' it reads. ''The health care delivery system is incapable of meeting the present, let alone the future, needs of the American public.'' The academy went on to recommend that the federal government allow a handful of states to experiment with different schemes for achieving universal coverage, a message the Bush administration said it would take to heart. And while Bush doesn't exactly have the budget space to enact a major health reform right now - frittering away $1.7 trillion on a tax cut for the wealthy will do that - he has been talking up a more modest initiative to help the uninsured buy coverage for themselves.
Feel like you've heard this all before? That's because you have. In the early 1990s, as health care costs skyrocketed and a deep recession drove up unemployment, large numbers of Americans began to fear losing their insurance coverage and having to face serious medical bills, much as they do today. Panels of experts began churning out dire warnings of systemwide collapse and, before long, health care reform was the dominant topic in politics. During the 1992 campaign, the popularity of Bill Clinton's health care pitch even forced the incumbent president, Republican George H.W. Bush, to craft a modest reform package similar in broad outlines to what his son offers today.
Of course, all the talk about health care reform in the early 1990s didn't exactly make it happen. On the contrary, in 1994 Clinton's ambitious health care proposal died an ignominious death: Even though the Democrats controlled both the House and the Senate, the plan never came up for a vote on the floor of either chamber. Ultimately, it unleashed such furious political opposition that the Democrats lost control of the House for the first time in a generation. So while it seems pretty obvious that another national dialogue about health care is beginning, the real question is where that discussion will go. Will it produce meaningful change? Or will it produce exactly what the last great health care debate produced - namely, nothing?
Certainly, there are reasons to doubt that large scale health care reform will take place soon. A major reason that the Clinton plan ran afoul of public opinion was that substantially expanding the reach of health insurance coverage inevitably requires substantially expanding the reach of government. The voters were pretty ambivalent about that prospect then, and they still are now. What's more, you can bet the special interests who fought reform so vigorously in the 1990s - particularly the small business lobby and portions of the insurance industry - will do so again.
But even if those conditions remain largely the same, one key barrier to reform may be gone: the sense among middle-class Americans that their current insurance policies are sacrosanct. If you remember the fight over the Clinton health care plan, then you probably remember the ''Harry and Louise'' ads on television. Those spots featured a middle-class couple sitting around their kitchen table, purportedly reading aloud from the Clinton plan and recoiling at its provisions. As Harry and Louise explained it, under the Clinton plan Americans would lose their choice of doctor, their access to life-saving treatments, and so on. The advertisements echoed what would become the main line of attack against the Clinton plan: that middle-class Americans stood to lose more from government intervention in health care than they stood to gain.
Such an argument is unlikely to be so persuasive today. When government reform failed in 1994, employers took it upon themselves to restrain costs through managed care - a method that, although effective, rankled most consumers. Suddenly, all of the dire predictions of Harry and Louise were coming true anyway, even without the dreaded Clinton plan. Health maintenance organizations and other forms of managed care limited patients to selected groups of physicians, second-guessed treatment decisions, and created longer waits for those treatments that were approved. Whether or not these changes were necessary for the sake of containing costs, the fact is they made the status quo a lot less appealing to the average American. According to the Harris Poll, for example, the number of people who said health insurance companies do a ''bad job'' of serving consumers jumped from 47 percent to 57 percent from 1998 to 2001 alone. That's one reason regulating HMOs, a cause that burst onto the scene in the mid-1990s, became so popular so quickly. It's also one reason that enthusiasm for a total overhaul of health care has quietly crept back to its pre-1992 levels.
Another traditional obstacle to health care reform has been the cost. Any successful program to extend health coverage to the uninsured is going to require raising taxes, and one might expect voters to resist, even if it's just a matter of redirecting money they'd be spending on insurance premiums anyway.
But will they resist? Here is where today's reformers can unleash some scare tactics of their own, thanks to another side-effect of the managed care revolution. During the late 1990s, as insurance companies slashed the money they paid doctors and hospitals, the providers of health care responded by downsizing and making their operations more efficient. They largely succeeded - it's one reason hospitals like Beth Israel Deaconess and Massachusetts General, which were in so much financial trouble just a few years ago, are climbing back into the black - but only by compromising their ability to deal with surges of patients. The most visible result of this shift has been a nationwide epidemic of overcrowded emergency rooms, a crisis Boston knows only too well. As recently reported in the Globe, Massachusetts ERs are now diverting ambulance traffic twice as often as they did just two years ago. And once patients do make it into the ER, they must frequently wait hours - even days - before getting admitted.
Stories like this scare people, as well they should. And because everybody, not just the poor, might someday need care in an emergency room, concern about ER crowding can motivate otherwise complacent, relatively comfortable voters into supporting expensive health care initiatives. Just consider what happened in Southern California this Election Day, where voters in Los Angeles - cradle of the antitax movement - overwhelmingly approved a property tax increase in order to support local trauma care. A major reason they did so was a series of television ads portraying paramedics desperately seeking emergency rooms that would accept their patients. The ads were dramatizations, but they weren't fiction: In LA, emergency rooms now divert ambulance traffic 40 percent of the time.
To be sure, it's a long way from enacting a local ER tax to making health insurance a right of citizenship, as many reformers now propose to do. And as if to demonstrate the extent of that distance, on the same day voters in Los Angeles approved their new property tax the voters in Oregon, about as progressive a state as you'll find on health care issues, overwhelmingly rejected a ballot initiative that would have required the creation of a universal health care program in the state.
But today's reformers have learned a key tactical lesson from Clinton: don't try to reinvent the entire health care system at once. That's why Howard Dean, who once proposed a Clinton-like scheme for Vermont, has said he'll work on insuring children up to the age of 22 first and worry about the adults afterward. Ted Kennedy may have a reputation as a radical, but his plan actually calls for leaving our current employer-based system intact. He'd simply require that businesses give their workers benefits and cover three-quarters of the cost themselves; employees would pick up the rest of the bill, with government subsidizing low-income workers who can't afford their share of the premiums. Then there is the National Academy of Sciences approach to health reform: letting a few states experiment with universal coverage until somebody gets it right.
Al Gore's proposal would appear to be the odd one out: The adoption of Canadian-style national health insurance would represent a sweeping change of Clintonlike proportions. But Gore may have learned a key lesson from Clinton, too. Clinton's determination to produce a workable compromise ultimately produced a convoluted scheme that, however elegant on paper, was impossible to defend from Harry and Louise's kitchen table jabs. Gore, by contrast, can describe his plan with one simple slogan, ''Medicare for All,'' thereby linking it to one of the most popular and successful government programs of all time.
Admittedly, it will take more than simplicity to sell large-scale health care reform right now. If Congress can't even pass HMO reform, a relatively modest measure that would merely regulate the way insurance companies make decisions about treatments, the prospects for more sweeping measures would seem pretty slim. But the plight of the uninsured and the anxieties of the currently insured are getting worse, and this means the political appetite for health care reform is likely to increase. Ted Kennedy obviously thinks it will. And judging by all his newfound political soulmates, he's not alone.
This story ran on page D1 of the Boston Globe on 12/1/2002.
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