Well, maybe. It is true, for example, that the Bush administration is now debating a health-care package that will be unveiled during the president’s State of Union Message on Jan. 28. It is also true that current Democratic presidential candidates have been talking up health-care reform as they stump New Hampshire. Meanwhile, at least 30 different reform bills are pending on Capitol Hill, and a small army of congressional Democrats staged town meetings around the country to stoke public indignation on this presumptively hot issue. Take it from Doug Bailey, a respected Republican consultant: health-care reform is nothing less than “this generation’s social security.” Or take it from Wofford himself: “This is an issue that affects almost everybody. The whole middle class is affected.”
There are, sadly enough, several important flaws to this theory. One is the plain fact that there is no real consensus, even among Democrats, on the best way to fix the nation’s health-care system. Another is the certainty that any reform proposal must pass muster with some of the most potent interest groups in American politics-doctors, hospitals, lawyers, insurance companies, unions, big corporations and millions of tax-phobic retirees. The truth about health care is that almost everyone has a vested interest to protect-and while almost no one doubts that real reform is coming, few experts think Congress will be able to pass a major health bill this year. And then, of course, there are the voters. Despite the uproar over Wofford’s victory, recent polling provides precious little evidence the electorate is hopping mad about health care. By one survey, 61 percent of the public expresses satisfaction with the current system. Another poll by the same firm, Public Opinion Strategies of Alexandria, Va., shows that health care ranks ninth among current voter concerns-well behind the economy and jobs, and slightly behind drugs, education, poverty, crime, the federal deficit and the environment. The health-care system, according to this survey, is the No. 1 issue for only 3 percent of those surveyed.
Still, virtually all policymakers and health-care experts agree that major change is needed. One reason is the continuing disparities in the availability of care: while 5 percent of the population consumes 50 percent of the U.S. health-care expenditures, an estimated 36 million Americans have no medical insurance at all. Administrative costs are soaring, billions of dollars are wasted on unnecessary care and the medical profession is being battered by gargantuan malpractice awards. But the real concern is the system’s overall cost. Total U.S. health-care spending has now reached $738 billion a year, or about 13 percent of the gross national product. That is almost double the percentage reported by other industrialized nations (chart), and there is no end in sight. If current trends continue, health care by one estimate will consume 26 percent of GNP-more than a quarter of the nation’s total economic output-by the year 2030. In the American system, says health economist Lynn Etheredge, “providers do what they want and patients pay [the bills] without anyone asking about the value of what’s being delivered. We couldn’t design a more inefficient, ineffective and costly system than the one we’ve got.”
But the current debate is nearly incomprehensible to many voters. “Health care is the most complicated public-policy issue this country has discussed since the 1930s. It is fundamental and it is huge,” says Deborah Steelman, who presided over one of many blue-ribbon studies on health-care reform. Steelman’s group, the Advisory Council on Social Security, concluded that there was not enough consensus on the basics and that Congress should opt for incremental reforms. Broadly speaking, however, there are only two approaches to organizing the health-care system, and they are the same two options that Americans have been debating since the 1940s. One is a national health plan-making government the controlling operator of the system. The other is to overhaul the present mixed system in the hope of making market competition work better. “These are fundamentally different alternatives,” Bush’s budget director, Richard Darman, said recently. “If we wish to have a coherent approach to reform, the political system will have to choose one of the conceptual alternatives.”
The Bush administration, unsurprisingly, is ideologically committed to free-market reform. Although the details of its plan won’t be disclosed until after the State of the Union address, the administration apparently hopes to use income-tax credits to help uninsured families pay for health insurance and to promote what is known as “managed care.” Managed care essentially means pushing millions of Americans into HMOS, or consumer cartels. In theory, these groups will do a better job of deciding how much care and what kinds of care are necessary. That is one way of fixing what experts see as the main flaw of the present system-the fact that consumers do not know what works or what it should cost. Managed care is a gradualist approach to controlling costs; tax credits are a gradualist approach to expanding access.
A compromise approach to reform is known as “play or pay. " Although they differ on details, two of the Democratic presidential candidates, former senator Paul Tsongas and Arkansas Gov. Bill Clinton, have chosen this tack. Play or pay also is being pushed in Congress by a group that includes Senate Majority Leader George Mitchell and Sen. Edward Kennedy. Like managed care, play or pay is an attempt to reform the current system. In essence, it means requiring employers to provide health coverage for their workers or pay taxes toward a government-run insurance plan. Critics say play or pay won’t work because employers will find taxes cheaper than providing medical coverage. If so, they say, government will eventually be forced to provide a national health plan anyway.
Then there’s full-blown national health insurance. Among the Democratic contenders, Sen. Bob Kerrey has essentially staked his candidacy on what he calls “Health USA,” a federalized health plan administered by the states. Sen. Tom Harkin has a plan to “guarantee” quality care for all, but the Harkin plan is notably short on specifics. Former California governor Jerry Brown endorses a variation on national health insurance that is known as the “Canadian plan.” In Canada, the government provides health insurance for all; costs are controlled, in part, by setting doctors’ fees through negotiations with medical associations. As a result, Canada spends less than the United States on health care-about 9 percent of GNP instead of 13 percent.
But any form of national health insurance implies higher taxes, more bureaucracy and big trade-offs for the consumer, such as enforced delays and rationing in the supply of medical care. Critics say Americans won’t tolerate that-and the dilemma, as former U.S. surgeon general C. Everett Koop says, is that Americans demand immediate access to health services, state-of-the-art technology and limited price as well. Reform can accomplish any two of those goals, Koop says, but not all three.
Explaining these stark choices in 30-second sound bites is arguably beyond the capability of any presidential candidate. But the Democrats are trying anyway, and George Bush may be forced to follow suit. For the voters, the likely outlook is a 10-month barrage of gobbledygook and political overpromising-and no real assurance that the health-care mess will be resolved any time soon.
