The Politics of Health Reform

...I do not believe that is the case...

...But I must begin with some more general remarks about why the administration developed its complex and complicated program...

...We are also required to make a commitment to evaluate and learn from the experiments and to utilize the information thus gathered to improve programs...

...Perhaps of even greater significance is the opportunity provided for opponents to argue that phasing does not require enactment of the full program at one time, that at most we should enact the first step and see how it works before debating the next...

...I will discuss three central questions: What should the goals of reform be...

...Mobilizing Political Will What sorts of ideas and political mobilization will it take to push reform in the right direction...

...That can happen, but only if we understand that there is a more comprehensive agenda than the one each group would independently pursue...

...It is ironic that the administration is forced to choose between employer burdens that will cost jobs and subsidies requiring the tax increases it sought to avoid...

...absent universality, costshifting patterns can continue...

...Our students (I use the broadest definition) cannot sort out our advice...

...Democrats and Republicans are distinguished by their definitions of vulnerability and of adequate assistance, as well as by how completely, having set up the market, they are prepared to step aside...

...Over time, disparities in insurance and in care are likely to grow...

...I write before 48 • DISSENT Health Reform the administration has made public the full structure of its plan...

...Skeptics and cynics will argue that new expenditures can always be financed by taking money from areas where it is being wasted WINTER • 1994 • 43 Health Reform rather than from increased revenues...

...It makes it much more difficult to build substantial progressivity into insurance financing and adds inefficiency to the total system...

...There is no formula to guide our behavior when we are called upon to balance our role as educators and our desire to be "realistic...

...They imply the need for a structure that can determine the citizenry's perceptions, translate them into a budgeting process, and reach necessary collective decisions...

...Rather, it is that as each phase is implemented, the constituencies that would be affected by the remaining phases shrink and their voice grows weaker...

...Worse than that, they may conclude that our incomplete analysis of an option (for example, a program such as an improved Medicare for all) stems from the fact that the option is seriously flawed...

...In 1965, Senator Clinton Anderson, then leading the legislative battle for Medicare, explained that Medicare would be "the equivalent of putting a Blue Cross card into the pocketbook or wallet of every elderly American...

...One can certainly imagine that if the administration had called for rapid changes in health-financing arrangements without a call for equally rapid delivery-system changes, many health-care analysts would have argued that it hadn't done its analytic homework...

...Of course, our existing trillion-dollar health system has important economic impacts, and comprehensive health reform will have important economic ramifications...

...The danger is obvious...

...That, however, is not a sufficiently high standard to which to aspire...

...After all, the desirability of "comprehensive reform" was the (somewhat unclear) message sent by the polls and the (very clear) message sent by the academic community...

...I distinguish that meaning from the one that we have heard about under programs of "play or pay" and employer mandates, where universal often seems to mean "everyone is insured, albeit in different ways, and insurance is financed, albeit from different public and private sources...

...We fear that government not only has a capacity to "screw things up," but is likely to do so frequently and in big ways...

...We are different, and those differences make a difference: we do not have a strong (or even a weak) labor or left-of-center party or a united labor movement that has the power to behave as a truly progressive social force or a strong progressive caucus of elected officials...

...Yet, it is the case that the shift from premiums to taxes would have entailed a particular difficulty: it would have had significant unfavorable impacts on the health insurance industry and its employees...

...Nor is it clear that, if enacted, it would achieve the requisite goals of universality and expenditure restraint...

...Although many among the public at large suspend belief in everything except individualism, for others—particularly elite members of the establishment—prevailing skepticism about government's ability to do good is accompanied by a deep belief in the ability of the competitive market to accomplish that end and to do so automatically...

...The proposal has become overly complex (how many Americans understood the early Health Insurance Purchasing Cooperatives, the later Alliances, or even the broad outlines of managed competition...

...I cannot imagine that the president is entirely comfortable with the implications of some of the substantive micro details of the health care reform proposal as they have evolved...

...In turn this will provide ample opportunity to visit and revisit the reform package and to delay full implementation...

...Perhaps there will be sufficiently diverse individual behaviors to protect the body politic from the dangers I speak of...

...This may turn out to be a significant error...

...Thus, though the interest groups one encoun44 • DISSENT Health Reform ters in the health field are unique to that arena, I believe that the politics of health reform is dominated by something much more important than those groups: and that is the preconceptions I have discussed...

...Health care policy is part of social policy...

...alter long-standing practice criteria, standards, and patterns...

...It is not clear that such a program can be enacted...

...It will be difficult to overcome the fears of the unknown and unexplainable, to get people to support that which they cannot understand...

...In my judgment, if that education is to take place, members of the academy will have to alter their behavior...

...Our potential allies in the quest for health reform are those who are concerned about our social condition, about homelessness, hunger and malnutrition, cities infested with crime and drugs, the quality and availability of good education, racism and discrimination, and about that most basic of matters: America's radically unequal income distribution...

...Their economic ideology is a distorted version of Adam Smith's capitalism, without the nuances, qualifications, and wisdom of the master...

...It examines how the president's early decision in favor of employment-based private insurance rather than tax-based social insurance led to an unnecessarily complex program...

...Yet who among us believes that we will really improve the health of the citizenry if we do not deal with the conditions of life...

...I do have a (readily understandable) bias in favor of a full articulation of the issues and of debate and public involvement—in a word, of education...

...Still, one would be tempted to defer to the administration's political judgment if one believed that this approach had been selected because it was a desirable political strategy in achieving health reform...

...Nevertheless, the administrative savings achieved thereby would be much less than in a social insurance program that eliminated the underwriting function and the associated marketing expenses of insurance companies and that might eliminate their intermediary fiscal responsibilities...

...Nevertheless, one can sympathize...

...The second matter—implied by my comments about universality—is the importance of breaking the link between insurance and employment...

...Candidate Clinton's healthreform rhetoric included slashing attacks on health insurers (attacks with which Americans identified...

...It would be preferable to develop a full scale federal social insurance program...

...If not government, then who other than insurance companies...

...Unfortunately, these are not the only consequences of the basic structural decision...

...at the maximum, they make it unlikely that the new health reform will ever be fully implemented...

...These emphases are not entirely positive: they create additional difficulties...

...An emphasis on access reminds us of the nonfinancial barriers to care, of the need to act on the supply side of the equation, to mount outreach programs, to expand community health centers, and to be concerned with the non-medical determinants of health...

...and appears threatening...

...Of course, it is possible to develop and implement standard billing and payment systems that produce some administrative savings...

...The first is that the program, now so comprehensive that it is called upon to reform the delivery as well as the financing of care, combines changes requiring very different time frames...

...Although I see an important role for states in administration (on matters such as health-care budgets...

...That is especially the case now that economists stand near the center of health care decision making...

...There is much that we can commend...

...But the details are the logical consequences of very early macro decisions...

...one can hardly imagine changing a trillion-dollar industry in basic ways and leaving everyone and everything in place...

...By "a significant error," I do not mean merely that the administration has selected an approach that isn't as clear and neat as one that I might favor...

...Furthermore, if the program fails legislatively or operationally, the debate is not likely to have done very much to inform the public of the various options, which would make it easier to mobilize around a "single-payer" approach at a later date...

...Rather, I mean that in opting for this general construct, it was forced to a set of specific details that confound and constrain its proposals...

...The latter is the case for a number of reasons...

...In a very real sense this basic choice was influenced by the nature of contemporary politics...

...The first is the importance of defining the term "universal" to mean "within the same program...

...Marginalism becomes more than an analytic technique...

...These twin goals may appear to be merely another (and more complex) way of stating the oft-repeated definition of the problems that beset us: health-care expenditures are rising rapidly and represent too high a proportion of our Gross Domestic Product...

...One wonders what might have been if that point had become the centerpiece of an educational campaign for a single-payer proposal building on something the American people are already familiar with, such as an expanded and improved Medicare system for all...

...The public could understand, identify with, and organize around this succinct explanation...

...Debate at the abstract and rhetorical level may yield one answer, debate about specific public-policy initiatives may yield quite another...

...The administration was forced to undertake too much because of the logic of its earlier decisions...

...Nor do economists' experiences as economists equip us with relevant expertise on issues of political feasibility...

...Thus, although the tactic of phasing has a certain appeal, it may well make the enactment battle much harder...

...If not taxes, then what else but premiums...

...However, the perception held by political leaders is that there is so much mistrust of government and of increased taxation that it is preferable to develop programs that are controlled by the invisible hand of the market rather than to opt for the all-too-visible alternatives developed by "bureaucrats...

...But that has changed...

...Increasingly, Congress has been asked to rely on employers to fund social programs (for example, family leave, child care, health insurance) that proponents find meritorious, but that cannot be paid for collectively out of existing tax revenues...

...That structure need not be invented...

...One certainly could not assume that talk show hosts would state and restate the analytic point that tax increases do not represent health expenditure increases and that as taxes increased premiums would be reduced in equivalent or even greater amounts...

...Furthermore, under a phasing timetable, program expansion will become hostage to deficit reduction, and economic and political developments not directly related to health care...

...Its importance is reinforced by the assumption that public policy will in any case be guided by this view and, therefore, that if one doesn't want to be laughed out of court (or the White House mess) as irrelevant, perhaps naive, one should structure one's ideas within that framework...

...Something different is expected of us...

...Other industrial nations, even those with national health insurance or financing systems, also share a capitalist ideology...

...Choices remain...

...We were pleased that the un- and underinsured would not be told to wait for better times or, as the words of the old labor ballad put it: "Work and pray, live on hay...

...HMOs cannot expand rapidly while maintaining quality...

...There must at least be major federal financing and a set of federal performance standards...

...benefits...

...The training and education of economists predisposes us to think in terms of marginal change and continuity...

...What sorts of ideas and political mobilization will it take to push reforms in the right direction...

...Nevertheless, there are three matters that should be noted...

...Such a move entailed obvious political difficulties, not unrelated to the fact that in the United States premiums are viewed more favorably than taxes (even though the latter can be adjusted to ability to pay...

...This message also resonated within that part of the body politic that preferred inaction: since one couldn't know, and do everything and since there was no point in doing only some things, there was an intellectual basis for doing nothing...

...I do not believe I exaggerate the overall impotence of an organized liberal force (in contrast with the considerable contribution made by individuals of liberal persuasion...

...Many who could accept changes in the flow of dollars fear the unfavorable impacts they believe they would encounter in the delivery of care, in relationships with physicians, even in their opportunities to choose their own physicians...

...It should be clear, however, that in providing freedom to states, I am not suggesting that it is sufficient simply to describe them as our experimental laboratories and let it go at that...

...It takes far less time to change the flow of dollars and payment criteria than substantially to increase the proportion of primary care physicians...

...This attitude toward government colors much of our contemporary political discourse and policy proposal formulation...

...develop the quality measures that managed competition requires...

...There is a real danger that we would not remember the most vulnerable (and the most costly) individuals and families and would postpone indefinitely the enactment and implementation of the last phases...

...Though few of them would be likely to exercise that option at this time, some might do so...

...I see little reason to be optimistic that fragmentation of insurance and financing provides us with a socially stable solution...

...Many were heartened by the administration's apparent recognition that, except for temporary price controls, cost-containment efforts can be effective only if they are joined with measures to make insurance coverage more universally available...

...Shifting over $500 billion from premiums to taxes also entailed substantive difficulties: the shift would be accompanied by real dislocations and disruptions...

...It is a tribute to the president's intellectual honesty that he notes that single-payer taxes would be less than today's premiums...

...Political and operational logic, regrettably, are not synonymous...

...Nevertheless, we will remain a mere platoon if we accept that narrow economic definition...

...perhaps forty million Americans are without any health insurance protection (and millions more have inadequate coverage...

...Thus, the problem of taxation has not been avoided: we need new taxes because we cannot rely on replacing, as the president put it, "over $500 billion in private insurance premiums, with nearly that much in new taxes" [emphasis added...

...President Clinton was forced to wrestle with the need to have someone collect the requisite funds...

...WINTER • 1994 • 51...

...Each of us will make his or her own judgment in particular situations...

...I believe the goals are more than that...

...Under the administration's proposal, it would remain so...

...What makes our politics and our capitalist culture so very different is the potent combination of a deep belief both in capitalism and markets and in individualism...

...Yet, I believe that in the case of health reform (especially in relation to programs that call for severing the link between employment and insurance), the academy has leaned in one direction and has provided less than the requisite information...

...Goals of Reform I believe that health-care reform should be structured to achieve two broad goals...

...In contrast, health-care-delivery reform is a long-range and continuing endeavor...

...Appropriately concerned about the plan's economic impact on small business and the political impact of business opposition, the president has referred to the need for a payroll-related cap on mandated contributions—with subsidies to WINTER • 1994 • 47 Health Reform make up the difference between the cost of insurance and the premium payments by firms...

...But it is not an idiosyncratic view...

...Aware that the various actors in the existing system could find ways to circumvent partial "solutions," and that "the health-care system is akin to a balloon: if you press at one point, it will pop out somewhere else," health-care analysts have strongly recommended general solutions...

...Even as the administration believes in an active role for government, it also believes in a restricted role: to help develop markets that operate under competitive conditions, to assist the most vulnerable among us to enter those markets, and then—insofar as possible—to step aside...

...close hospital beds and reduce duplication in programs...

...This is not the occasion on which to present the details of a program that would bring us closer to the two goals I have referred to...

...restructure the number and type of residency training programs...

...I also believe that, given the unequal distribution of socioeconomic status and of health-care needs, the implementation of a universal health insurance program is necessary but not sufficient...

...At the minimum, the constraints mean that the achievement of universality and equity are delayed...

...Flaws in the Proposal I do not believe that the administration opted for managed competition after arraying the various alternative health-care and financing reform programs and carefully examining their political, economic, and health-care costs and This article is adapted from a paper presented at a seminar on "The Politics of Health Care Reform," which was part of the program "Future Directions for American Politics and Public Policy" at Harvard University...

...We reject it because we believe it isn't politically feasible, and it becomes just that...

...Thus, our goals involve macro (how large the pie) as well as micro (how the pie is divided) policy...

...Are the Clinton administration proposals heading in the right direction...

...More than that, it is the "respectable" view, certainly among economists, but among others as well...

...Our role is not that of the 50 • DISSENT Health Reform president or of our elected representatives...

...Health-financing reform is something that can be and, in my view, should have been done quickly...

...We have helped constrain the debate by accepting the definition of the world as it is conventionally believed to be instead of describing the world that we hope might be (and perhaps, without our knowing it, is...

...Rather, I believe that the choice— managed competition (and the language used in its presentation)—fit with a set of political and economic preconceptions, attitudes, and biases that are held by the "body politic...

...there is also much that we should regret...

...With mistrust rampant, even the promise of such subsidies (for only a limited period) may not be sufficient to generate political support for the program...

...We need to make certain that the laboratories are working toward the same goal, trying to answer the same question, adhering to a prescribed set of ethical standards...

...Medicare/ Medicaid savings well...

...it becomes a pattern of thought, even a guide to action...

...and there are limits to the amount that can be found in our continuing return to the (bottomless...

...Furthermore, since employers who do not provide health insurance at the present time (often inadequately defined as "small business") were opposed to reforms that imposed new financial burdens, and since it was clear that desired cost-saving system reforms could not be developed rapidly, the administration was forced to recommend a long phase-in period and the provision of employer subsidies financed out of the (presumed) future savings in existing federal health programs...

...Because of those expectations, we will confuse our various audiences if we stop being professors and become politicians...

...some of them promote universality and equity, some of them contribute to the fragmentation of the population and to differences in access to care...

...Nor is it clear that the administration will be able to find such a description...

...The danger is not merely that battles would have to be fought again and again and that the nation's span of attention may be insufficient...

...It would have done better had it been less captivated by the presumed virtues of privatesector competition in financing care and less fearful of expanding social-insurance funding...

...In the health-care debate too many of us have been tempted to play at being politicians, to make political judgments about feasibility and to temper our recommendations to make them fit this or that view of political reality...

...Even so, since not all employers can bear the burden of funding health insurance, systems that subsidize and shelter low-wage employees and low-profit employers—and that need public funds—have to be developed...

...First is the fact that the very considerable administrative savings associated with a non-employment related tax-based social insurance system are no longer generated...

...and (2) the health care resources so budgeted would be distributed equitably in relation to individual medical needs and the benefits and costs of care rather than in relation to individual income, wealth, power, or status...

...I believe that will occur when we recognize that health care reform does depend upon a concern about costs and the misallocation of America's resources, but that it also depends upon whether enough of us are prepared to work at translating concepts of decency, humaneness, cooperation, universality, and justice into policies that would protect all members of the American family...

...In turn, since nonexistent savings cannot be used to finance additional care for today's un- and under-insured, increased tax revenues are required...

...These delivery-system changes must be 46 • DISSENT Health Reform implemented over a long period of time in order to reduce inevitable dislocations that would affect patient care, teaching, and research, but also in order that providers, patients, and prospective patients understand and accept the various changes...

...Earlier statements had helped allay the fear that, as in the past, universal coverage would be held hostage to the success of cost-containment efforts...

...The outcome is a program that is not readily understood...

...You'll get pie in the sky when you die...

...There is no equivalent description of today's proposal...

...Since there is little that is intuitive about the proposal, opponents will be able to sow confusion and benefit from its presence...

...That combination yields a capitalist ideology not tempered by democratic socialism or motivated to search for areas where cooperation can substitute for competition and community for individualism...

...The latter can too easily translate into market segmentation, reductions in quality, and allocations that reflect our grossly unequal distribution of income...

...Yesterday's alchemists who sought to change base metals into gold have been replaced by today's legislators who want to create the free lunch: that is, social programs that are valuable and (presumably) open to all, but which (apparently) don't have to be paid for...

...Without administrative savings and with the need for new taxes, the administration was forced to emphasize (not merely favor and rely upon) delivery-system reform (managed care and managed competition) as cost-saving mechanisms...

...build new HMOs and expand existing ones...

...A second problem stems from the fact that in avoiding a shift to taxation, the administration continues the linkage between insurance and employment and places primary reliance on employer funding...

...The United States is a nation with a deep (perhaps growing) skepticism about government's ability to achieve stated goals and about the wisdom and honesty of elected representatives and government employees...

...In any case, the availability of a state option would make it easier to move in that direction at some later date, since the shift would not have to occur for the entire nation at the same time...

...Too many professors have stated privately that a singlepayer approach would be the "best way to go," but have misled the public by not sharing that conclusion and its reasons...

...Rather I suggest that many in the administration share that assessment and belief...

...Perhaps we will enact a piece of legislation, even a piece of "good" legislation...

...We should seek to develop a system in which (1) the allocation of financial and real resources to health care would be consistent with our collective perception of the benefits that care would yield and the alternative benefits that would be generated were those resources used in other ways...

...Nor is the problem merely one of phasing in the various predetermined parts...

...They do not know which role we play...

...Who among us believes that we can really achieve an equitable distribution of health care and of financing in the presence of the most unequal distribution of income among industrial societies...

...The administration has developed a plan that fits with its biases about the role of competitive markets...

...Only then can we make certain that the United States has a truly universal program covering all residents...

...We see ourselves this way in part because we have permitted others, especially in recent years, to define health reform as an economic policy issue rather than as an issue in social policy...

...Nor do I believe I exaggerate the dominant and deep-seated beliefs shared by the elite leadership in the efficacy of competitive markets (and in the creation and strengthening of markets where they do not exist or are not sufficiently strong...

...I fear that intuition is not a substitute for experience and know that introspection is not a particularly powerful research technique...

...The third matter relates to the role of states in a universal health insurance program...

...Some of them are better, some of them are worse...

...The actors change, but the story line remains the same...

...The one without the other is insufficient...

...The administration could have done better...

...Nevertheless, even those criticisms pale against the major issue: employment-linked and funded programs are not and cannot be models of universality, progressivity, and equity...

...In seeking to present delivery-system reform in tandem with financing reform, the administration has hurt its cause...

...There is no logical reason (I do not deny the importance of history or politics) to continue to tie the availability of insurance or its financing to work...

...Given that individuals enter and leave the labor force, work sometimes and at other times are unemployed, change employers and geographic locations, live in families with different numbers of WINTER • 1994 • 49 Health Reform earners, and that payrolls and profits of employers and wages of employees vary greatly, linkage complicates rather than simplifies the availability of insurance...

...That attitude is not dependant on the nobility of purpose for which the funds are sought...

...In accepting the distortions, they ignore a guiding principle of the marketplace: caveat emptor...

...It is easy to understand that individuals who are convinced that government revenues will be misspent because those who administer the funds cannot be trusted and that, even were there no fraud, graft, or corruption, large sums would be wasted because government programs simply cannot attain their objectives, would be reluctant to shoulder an increased tax burden...

...Surely, it is reasonable to suggest that the first step in political mobilization in support of an idea should be a defense of the idea itself...

...If, however, the administration cannot be dissuaded from mandating employers to provide insurance, it should offer states an option to move to a tax-based program...

...I claim no expertise on such matters...

...The logic of "dipping your toes in the water" before deciding how much further to move could prevail over the admonition attributed to Winston Churchill that one should not leap over a chasm in two steps...

...What may be exaggerated is the degree to which the public at large, though skeptical of government, automatically accepts market ideology and rejects solutions that expand government's role and responsibilities...

...These stemmed from the fact that the president was unprepared to advocate moving the billions of dollars now paid by business firms and individuals to insurers and care-delivery organizations in the form of premiums to government or quasigovernment structures in the form of taxes...

...They stress collective decisions and imply the need for budgets...

...review of quality-assurance programs...

...Divorced from the need to consider questions of acceptability, legislative timetables, and implementability, it is easy for academicians to demonstrate that it is advantageous, indeed, necessary to tackle everything...

...It is called government...

...We have helped constrain the breadth of the debate...

...It is a restricted view of government and a narrow view of the forces that motivate individual behavior...

...The administration is enamored of managed competition as a strategy, but is not so captivated that it is willing to place exclusive reliance on the market to contain costs...

...This view places primary emphasis on government as the institution that structures (economic) incentives so as to encourage individual behavior associated with desired outcomes...

...Thus, with a need for new dollar resources, an inability to find them within existing revenues or to raise them in sufficient amounts through additional taxes, there is a political logic to stretching the phase-in period and to calling for cost containment to precede enrollment expansion...

...Nonetheless, it seems clear that, though overly complex, health care financing would be improved were the anticipated proposals adopted (I am much less certain about the short-run impact on delivery of quality health care...

...Regrettably, the administration has been pushed to the step-bystep approach because of its much earlier choice of an employer-mandated approach and the difficulties engendered in relation to financing and cost containment...

...The definition of "phasing" (whether it describes a process of enactment or implementation) has always been a source of contention...

...It is problematic whether a program with a long phase-in period can be enacted at all since the public may not readily mobilize in support of something that will take effect in the distant future...

...While recognizing that the administration's reforms would provide coverage to millions of Americans who now have no or inadequate insurance and would improve the way health care is financed in the United States, I argue that we would still fall short of the universal and progressive program our nation ought to have...

...Our judgments about feasibility might be wrong...

...He argued that a single-payer system (which, he said "would have the least administrative cost") "would be significantly dislocating in the sense that overnight, in a nation this size, you'd have all the people who are in the insurance business out of it . . . " Perhaps it is not an entirely unreasonable position for the leader of a nation whose military sector is shrinking and whose economy is not yet vigorously "growing" jobs to eschew the quest for efficiency and to view health sector inefficiencies as assets...

...setting of health-care priorities that reflect the culture, traditions, and needs of particular population groups), that does not imply that states "can do it alone...

...The very complexity in the administration's program— which comes from trying to do through employer premiums what should be done through taxes—is a persuasive argument for a social insurance program...

...Attempts to contain health expenditures must be based on predetermined budgets rather than on price competition...

...Unless health reform is defined in broadest terms, we will achieve little...

...In his August 16, 1993 address to the National Governor's Association, the president recognized that this was the case, but tried to put a positive spin on the loss of the potential efficiency gains...

...Yet, I fear that others who call upon the states to be our laboratories do so in an effort to delay the implementation of a national program rather than because they believe in the experimental method...

...Who among us believes that a deficit-ridden public sector can compete with a rich private sector unless we choose a collective response to human needs...

...It did not stumble into its chosen structure by inadvertence: it embraced the concept of managed competition because it believes in the economic theory on which the presumed benefits rest...

...The New York State Department of Health proposed just that in its UNY*Care program, which retained multiple insurers, yet arranged WINTER • 1994 • 45 Health Reform payment by a single payer...

...Even if managed competition were an effective long-run cost-containment strategy, expenditure savings would prove insufficient in the short run: budget structures are not easily developed...

...I will then turn to the consequences that follow from that fundamental choice...

...Nevertheless, the centers of both parties do share a belief in and a desire for market solutions...

...Much depends on how the issues are put, indeed, on whether they are put at all...

...It is this belief in government as landscape architect, the designer of level playing fields, that defines much of Washington activist politics...

...It is the establishment view...

...and build new regional structures to rationalize and share institutional responsibilities...

...It already exists and operates at various levels...

...I do not mean to suggest that this administration's sole concern in developing its health plan is that it meet the private-sector bias of American political reality as assessed by the elite...

...The platoon must and can grow into an army...

...Thus, it supports caps, limits, and global budgets...

...Not unreasonable, but certainly not good policy...

...they stress the allocation of resources and, thus, emphasize access rather than insurance...

...Large parts of the electorate (and an even larger proportion of talk show hosts and their callers) and a significant number of elected representatives express their skepticism and antipathy in a confrontational rhetoric that reduces the probability of negotiated, compromise policies—a rhetoric designed to destroy the opposition even at the cost of having a similar impact on representative democracy...

...In these and other areas there are platoons akin to ours whose members search for ways to mobilize so that they, too, can grow to battalion and regiment size, expand into divisions, become an army...

...As a consequence, the politics of health reform is not unlike the politics of a host of other specific areas...

...If we (and others in the academy) emphasize the doable and fail to provide a rich discussion of other possibilities, ruling them out on the grounds that, as the president put it in dismissing the Canadian single-payer option: "I don't think that is going to happen," we do not help equip the citizenry to debate the full range of issues...

...My final comment on political mobilization stems from the observation that many who despair that sensible health reform will be soon enacted feel that we are weak, and believe, as a colleague once put it: "We have a platoon when what we need is an army...

...We should encourage it to continue to do so...

...The administration shares some of these views...

...Retaining insurance companies in order to promote competition and avoid large tax shifts leads to a number of unfavorable consequences...

...True, every comprehensive reform program shifts dollars and involves some dislocations...

...Whatever the "packaging" difficulties, the substantive implications of the administration's approach are of even greater concern: specifically, the call for a lengthy phase-in period and the emphasis on the need to generate dollar savings that can be set aside to help pay for insurance and care for the uninsured and for those who have fewer benefits than the standard benefit package will call for...

...When—I do not write "if"—enough of us understand that what we are about is trying to redefine the kind of society we live in, the health care platoon and all the other platoons will discover each other and will find that together they are an army...

...While I have been critical of the administration's approach, my argument would be incomplete and less than fair if I did not make clear that within the basic structure of managed competition as a way to organize the delivery system and employer mandates as a way to finance insurance—I believe it is useful to separate these two—there still remain many opportunities to amend and improve the program...

...negotiating and bargaining with providers...