What We Need in Health Care
Fein, Rashi
It is clear that President Clinton will submit a health care reform package to Congress. It even seems clear that something labeled health care reform will be enacted. What is not clear is what...
...It is not the knowledge base that has been missing but the willingness to take bold steps...
...The last time we had such a freeze— and it worked—was in the early 1970s and applied to the entire economy...
...We are told that the first priority must be to cut the deficit, that the plan to do so must be perceived as "real," that the "bond market is watching," and that access will have to wait...
...We can be certain that if the president submits a measure that merely tinkers at the edges, the Congress will not enact a bolder plan...
...The President needs effective health care reform legislation and he needs it quickly...
...Already we begin to hear that first we must tame the inflationary pressures in health care and only then will we be able to expand coverage for the uninsured...
...Yet, that way of defining the reform issue may serve to constrain the president's program...
...There is much that states can do...
...Shockingly, the "managed competition" construct with which so many are enamored would lead to even greater constraints for more Americans...
...The president will also be told that such a freeze can't really work because, as in the early seventies, once it is removed prices will simply explode...
...There will be those who would compromise and settle for something better than what we now have...
...We must keep articulating our goals and keep pressing for a truly comprehensive program...
...A freeze will distress those who produce health care supplies and services...
...Not so...
...Not so...
...Who of us, after all, can presume that there is one single "best" way of organizing care across America's geographic, economic, and demographic diversity and that it can best be determined in WashSPRING • 1993 • 147 Clinton Proposes, We Respond ington...
...Will President Clinton, who knows how important this issue is to the success of his economic program and of his presidency, lead or be led...
...That battle for the heart and mind of the President is our battle as well...
...There are many details to be added...
...It is time for a new kind of federalism, a federalism that may help reestablish the elements of trust of government and of community...
...We know that without universal access the private sector will choose to reduce the expansion in expenditures by cutting benefits and services for those who are the most vulnerable...
...Unless we hold fast for something as good as we deserve, unless we keep talking about universality, public administration, tax support, full medical and health care benefits, elimination of cost-sharing and the paper work that accompanies it, freedom of choice of health care provider, we will lose the battle even before it is fought...
...Medicare is more complex than it once was, and its benefits are more limited than they should be, but it does enroll all the aged in a single program...
...Conversely, we in the United States have watched our choices become increasingly circumscribed...
...This act would indicate the importance the president places on health care reform and it would do so through deed, not words...
...The first battle will take place within the executive branch, among the various presidential advisers...
...That is what the battle about the president's health program will be about...
...We who want fundamental change that deals with both access and costs and who want to contain costs by reforming the system, though not by placing the burden of restraint on patients, understand that we cannot be certain of ultimate victory even if the president chooses the appropriate path...
...Some of the important characteristics can also be found in our own Medicare program...
...Though the United States is not Canada, much of the structure we should seek would have characteristics similar to those found in Canada...
...To achieve true universality and cost containment not based on denial of care we need and should press for the enactment of a tax-based, publicly administered, social insurance health care program...
...Will he dare to break free from the incrementalism that has characterized previous efforts...
...It is the economic dimension of the problem that propels the debate and will lead to action...
...But that's not the way it has to be...
...The U.S...
...That broad and useful definition has not bankrupted the Canadian provinces...
...There will be no massive distortions caused by a frozen health sector caught up in a 146 • DISSENT Clinton Proposes, We Respond runaway economy...
...That very pledge will help bring the various constituencies to the negotiating table...
...We benefit from the fact that we are not the first nation to reform an existing health care system...
...It will be supported by the public and large employers...
...A taxbased, publicly administered program can collect and disburse funds through a single entity and constrain expenditures by adopting a defined budget ceiling...
...What is not clear is what that something will look like...
...Through public administration and a singlerevenue collecting and provider-payment mechanism, Canadians have created an efficient health care system with low administrative costs and with a sense of community responsibility...
...Clinton should announce that the freeze will not be removed until we have enacted a long-run cost-containment program...
...Already we hear that Medicare and Medicaid savings should go toward deficit reduction rather than coverage expansion...
...We can fill in the details out of a well-known and rich experience...
...President Clinton should put in place an emergency wage-price freeze for the health sector...
...Furthermore, in large measure, both Canadian provincial systems and Medicare are financed through taxes rather than regressive premiums...
...the rest of the economy is characterized by stable prices...
...That link has impinged negatively on the availability of insurance, on labor mobility, and on the employment possibilities for high-risk individuals...
...It should be dealt with on an emergency basis even in advance of the submission of comprehensive reform...
...Canadians have also preserved the opportunity for patients to exercise free choice in selecting a physician...
...Nevertheless, it would be no more than temporary...
...Health care expenditures are close to $900 billion per year and rising rapidly...
...We must press for comprehensive reform...
...Canadians do not face costsharing via deductibles and co-insurance...
...A comprehensive program can use Canada and Medicare as a template...
...Will he press his economists for more than marginal change...
...Comprehensive reform cannot be segmented...
...This president, like President Carter before him, is being told that universality is a good thing, but not affordable till...
...Their savings on premiums will be a significant economic stimulus...
...He can do so in a way that will not only restrain the growth of health care expenditures but will also speed the adoption of a reform package...
...The president must act today, before expenditures exceed a trillion dollars...
...Unlike managed care, it relies on budgets, not on market competition, to constrain expenditure growth...
...Per capita health care expenditures are substantially less in Canada than in the United States...
...What should we press for as part of a long-run measure...
...The health reform program should provide comprehensive benefits analogous to those provided to our neighbors to the north: that is, such physician and hospital services as are medically necessary...
...The president should address the cost issue immediately...
...It is time for the people to be heard, time to drown out the voices of the naysayers, the incrementalists, and the economists who fail to grasp the difference between a social good like health care and the other goods and services produced in the American economy...
...Such a program would break the existing link between health insurance and employment, a link that schemes for managed competition and play-or-pay would strengthen...
...Will he reject those who will tell him that Canada is fine, but that the Congress wouldn't adopt such a different approach for the United States...
...tax structure is hardly a model of progressivity, but it is fairer than premiumbased financing...
...Nevertheless, states cannot really fund universal insurance without federal financial assistance...
...This is an important characteristic of a truly universal program and one that prevents competition by insurers around risk selection—a competition designed to exclude individuals who might need more than an average amount of care...
...Surely our Canadian friends must be confused by the behavior of this "bastion of free enterprise...
...I would hope that the president's plan would delegate important responsibilities to the various states, both because the states are closer to the people and their needs and priorities and because the states will provide laboratories for what might be turned "natural experiments...
...The president will be told that such a freeze can't succeed when applied to only one sector...
...We can build a better system...
...Since even the most optimistic among us recognize that major reforms would not be implemented and effective until two or more years from now, we will face a new expenditure base perhaps $200 billion higher than today's level...
...We know that if universal access is postponed till expenditures are stabilized, if access is held hostage to cost containment, we will not attain either goal...
...In that system major responsibilities related to administration and accountability would be turned over to government, not to the insurance industry...
...Clinton needs health care reform because his entire economic plan, his ability to reduce the deficit, to undertake new programs, and to strengthen America's international competitive position, rests on constraining the explosive expansion of health care costs...
Vol. 40 • April 1993 • No. 2
