Should We Support the Clinton Plan?
Brand, Robert J.
Health care reform is the critical political issue confronting the American left in 1994. How should we relate to the Clinton plan? Congress is not going to vote on our plan: a single-payer...
...until 1998 or 1999, legislative battles, the development of health alliances, and the continuing cost crisis will keep the health care issue in front of us...
...The plan still holds that people have to pay out-of-pocket for health services so as not to "over-consume," but correcting this is a long, continuing fight...
...Even though these tax payments would be cheaper to employers than the continu 198 • DISSENT ation of an insurance premium system, and even though they would replace the substantial burden of out-of-pocket costs, the president clearly felt that proposing a massive tax-financed system would risk sinking the Democratic administration...
...Our job is to make sure that the plan is not weakened...
...we must insist on universal access to comprehensive benefits for the least cost possible...
...The plan recognizes that although freedom of choice is a goal, it is not, now, a practical reality for most Americans...
...The more than nine million health care workers in the United States Vanessa Gamble will need protection...
...The administration saw a different industry—a power within the investment markets and, therefore, the Beltway...
...Permit me to tell the secret that everyone who has ever worked in health care knows: making a profit is very easy...
...We should remember that the power of the insurance companies lies in the capital they invest...
...Choice" recognizes that people want the freedom to choose their own physicians...
...This is a tremendous opportunity for organizing coalitions to go beyond the Clinton proposal...
...The plan creates a nationwide network of health care alliances, which, beyond the rhetoric, can evolve into a monitoring structure for the American people, preventing the worst profiteering of HMOs, insurance companies, and providers, defending equal access for the poor, and assuring real choice and services for those whom the gatekeepers exclude...
...Second, the administration decided that it could not fight the insurance industry...
...Fourth, the president's plan offers an opportunity to significantly benefit the poor...
...But they cannot be negotiated away...
...This, in itself, is a victory...
...Clinton's reform plan is a major change in the political landscape...
...But this was unacceptable to the administration...
...The Clinton plan simply recognizes this and gives people an expanded choice of primary care physicians and then the luck of the draw for specialists...
...They must have regulatory authority...
...The civil rights and antipoverty movements are small and overwhelmed by the growing polarization of American society...
...The president of the United States supports a national health care system that provides universal access to comprehensive benefits at an affordable cost...
...Health care reform is the critical political issue confronting the American left in 1994...
...The benefits package is broad...
...Third, the administration was unable to reach a decision on a fundamental issue of public policy and health economics...
...The women's health movement continues to confront restrictive antichoice measures, the exclusion of poor women from access to abortion, and a host of other issues...
...We need to make this an issue of justice for all health care workers...
...Fifth, the administration's plan has a fair chance of actually benefiting most Americans in the short run, even though it still leaves a significant left agenda...
...On some occasions he gives up too much (the economic incentive program...
...The abolition of Medicaid, which has evolved into an underfunded, discriminatory segregation of poor people into substandard health services, is a strong component of his program...
...If any of these things happen, the plan has no chance of success...
...The Clinton plan is not the best health care reform proposal...
...He reaffirms his support at every opportunity—his desire to provide the American people with a universal package of health care benefits that "can never be taken away...
...But we will need to mobilize to keep that agreement strong...
...While not elegant, this is a workable interim step, especially given the consumer advocacy and regulatory roles of the alliances...
...Similar attempts will be made to weaken the employer mandate or increase individual costs...
...Now we must confront the issue of how we support this plan...
...Yet even this hodgepodge will not pass without a significant left mobilization...
...The more and better you skim, the more you make...
...If we take the position that justice on these issues is our bottom line, if we lobby and push the ninety-two sponsors of single-payer reform to help the president make these bottom-line issues, we can win on them...
...A single-payer system covers more benefits...
...Here again we have the agreement of the administration...
...It controls health care costs to benefit the entire society...
...Therefore, the administration simply decided to split the insurance companies, assigning the large companies the task of organizing the American health system under some degree of competition and regulation and cutting out the small ones...
...Leftist support of the Clinton plan should be conditioned on the presence of the following features...
...Responsibility" recognizes that the right wing still mistakenly believes that individuals paying for health care somehow makes for a rational, high quality, low cost health care system...
...Combining poor people and working people into a single group of health care consumers may advance 196 • DISSENT Health Care Reform equality and lessen racial isolation in our urban areas...
...On some occasions we have not been happy with the results (NAFTA...
...I don't want to suggest that the alliance arrangement is the best way to organize oversight in the health system, but I believe that the alliances will play a crucial role in assuring greater equity in the health system...
...It allows freedom of choice for consumers...
...Feature 2: Clinton remains committed to offering each state the option of adopting a singlepayer system...
...All you have to do is serve healthy, that is, affluent, young patients...
...First, the president made a simple, tactical decision that he was unwilling to risk Democratic control of the Congress and the White House in 1996 by proposing a health care reform system that would require hundreds of billions of dollars in new taxes...
...We must also remember that this health care reform package has evolved without the leadership of any mobilized popular movement for change...
...But they seem to be preparing for a major fight...
...So what happened...
...It does nothing to correct the basic problem of market-based health care: profiteering by market segmentation...
...The great deal maker will destroy what is worthwhile in his proposal if he tries to make deals and move further to the center...
...All citizens, regardless of income, class, race, gender, sexual orientation, ability or disability, have the same power to get the health services they need...
...So what are we to do...
...Since all health care reimbursement is based on some form of averaging, if you receive an average payment for a patient SPRING • 1994 • 197 Health Care Reform whose costs are below average, you make money...
...They will be the first line of defense in preventing providers from discriminatory marketing practices...
...This is our health care agenda for the next five years...
...Feature 6: The health sector is going through a wholesale reorganization as providers prepare for reform...
...Single-payer institutes negotiated, global budgets and a universal right to health care in a single system and draws its substantial savings from administrative simplification...
...If the health care sector is simply another sector of the economy, then, in a capitalist society, regulation will be minimal, and growth will be encouraged...
...Congress is not going to vote on our plan: a single-payer system that would guarantee every American all necessary health services with no out-of-pocket costs...
...The AFL-CIO has prepared a set of proposals that offer some protection and a range of retraining options for health care workers during the reform process...
...Simplicity" recognizes that the United States spends more than 24 percent of every health care dollar on administrative costs compared to a maximum of 10 percent to 11 percent for other industrialized countries...
...Given these political priorities, Clinton has put together a fairly decent, workable (at least in the short run) program...
...Because this dilemma was not resolved by the Clinton administration, it opted for some recognition of entrepreneurial opportunities (managed competition) and some recognition of health as infrastructure (global budgets, premium caps, and health alliances as regulators...
...Trade unionists, consumers, seniors, working people who melt at the touch of presidential authority are really quite good at confronting and pushing state legislators...
...While the devil is in the details, the general direction of reform advocated by the president is positive and would offer substantial improvement for poor people and minorities...
...In fact, poor people with existing health problems are at considerable medical risk in HMOs...
...Security" recognizes the importance of universal entitlement to lifelong, comprehensive benefits...
...What Happened to Single-Payer Reform...
...But he is a skilled politician capable of assembling a majority for health care reform and he calls health care reform his highest priority for 1994...
...In health care they handle hundreds of billions of dollars of premium income each year, which they invest in the short-term capital markets during the period after premiums are collected and before providers are paid...
...We will have to track them through the legislative process, the regulation writing process, the formation of the alliances, and the process of state legislative action to build toward single-payer reform...
...Competing health care corporations will ration care to all those who cannot afford to buy their way up the hierarchy of plans...
...Under managed competition HMOs (Health Maintenance Organizations) will make profits by choosing some patients and excluding others...
...Feature 5: We also have to insist that abortion be assured as a woman's right and as a covered health benefit in this plan...
...The cost-sharing provisions are no worse for most Americans than the cost sharing we bear now, and the payment system moves us slightly in the direction of distributing costs by income (there is a cap on out-of-pocket expenses, there is a lower rate of co-insurance...
...Instead, we face a vote where the best we can get is a patchwork, uniquely American plan that recognizes the accelerating corporatization of American health care and tries to build universal access around the untested theories of managed competition...
...Without a concern for balancing social and economic policies in favor of the working class, Clinton health care reform is able to use an employment base, a competitive market of corporatized providers, and a potential shift to workers' out-of-pocket costs as the basis of his reform package...
...Single-payer health care ran into four problems...
...Savings" recognizes that our health care system costs a minimum of 25 percent more than those of our trading partners...
...But if the health care sector is a social necessity and crucial part of our infrastructure, then it should be regulated...
...The implementation of health care reform will take years...
...Forces to the right of Clinton want to deregulate, do away with the alliances and the budgetary caps, and weaken the employer-based mandate...
...The corporatization, consolidation, merger mania, and resultant shrinking of the health care work force will accelerate over the next few years...
...They cost less to care for...
...In the world of Washington gossip, it is hard to find a key player who won't privately admit that "single payer is the best...
...Let us be clear on what it will achieve: • Nearly everyone is covered, except undocumented workers, who are also excluded in singlepayer reform proposals...
...But for most people, these benefits are better than what they have now...
...If we want to build a democratic left, then working for health care reform at the state level is a good place to start...
...The pro-Clinton forces do not yet have the votes to pass their reform plan...
...This will be a focus of right-wing opposition to the Clinton bill...
...If national health care reform requires that workers pay more out-of-pocket or do not get relief from staggering out-of-pocket costs, this is an acceptable price to be paid...
...This is the Achilles heel of managed competition and why we really need single-payer health care...
...It believes that the industry is popular and strong, while single-payer advocates argue that it is despised by most Americans, who associate it with exclusion or claims denial...
...It continues to spend too much money on not enough health care...
...Therefore, we have five years for states to implement the single-payer system...
...Quality" recognizes that the United States does poorly in longevity and infant mortality and that we distribute mortality and morbidity by race, class, ethnicity, sex and geography...
...Third, the president has popularized a list of six principles of health care reform, a list largely taken from advocates of a single-payer system...
...Managed competition lets it continue to dominate the health sector...
...How should we relate to the Clinton plan...
...What happened to single-payer health care reform anyway...
...200 • DISSENT...
...Single-payer health care challenges this pattern of entrepreneurial behavior...
...That is why health care costs are now nearly 15 percent of our gross domestic product...
...Feature 1: Universal access, a primary goal in health care reform, requires cost controls...
...Managed competition that addresses these issues is an actual victory...
...For virtually everyone else, there is some access to health care...
...This means that provider organizations will not have the freedom to market only where they choose and to avoid certain populations and their physicians...
...It creates a single health system for all Americans...
...Feature 3: The right claims that the alliances will be huge government bureaucracies...
...It redistributes income in a progressive fashion...
...An Organizing Response The Clinton proposal, if it is to remain universal, comprehensive, and economically viable, leaves little room for negotiation...
...The plan includes a mechanism to control health care costs by capping health insurance premiums...
...The labor movement, which has played the largest role in demanding health care reform, is struggling to survive, to develop an effective method of organizing in a global economy, to achieve labor law reform, and to battle the runaway power of capital and the ethic of privatization...
...Second, this president has shown an extraordinary ability to organize a majority in the Congress...
...There is little history of HMOs effectively delivering health services to the poor...
...They are similarly unacceptable...
...Poor people, people on Medicare, nonunion workers whose bosses choose their health plans, people who cannot afford to pay for specialists, people who are not experts in medical practice and have to trust their physicians' choice of specialist—all these already have lost their freedom of choice...
...Without the inclusion of all these, we should be prepared to say "Not This Health Care Reform...
...Health Care Reform Finally, we have to remember that although Clinton is committed to providing some relief to the poor, he is not as committed to increased power or even equity for workers...
...Given its top-down history and its internal limitations, the Clinton health care package represents a substantial reform that offers improved care to a majority of Americans and establishes firmly the obligation of government to provide access to comprehensive care for all Americans...
...Although the caps are described as "fallbacks," there is no question that they will be necessary...
...Five out of six ain't bad...
...First, let's recognize how improved our position is...
...These state systems can then become the model for the next stage of health care reform...
...A plan that arbitrarily takes a health service and makes it unavailable except to women who can pay for it privately is simply unacceptable...
...Feature 4: The reality of inequality in our health system poses many concerns for poor people and especially for people of color...
...Clinton plans to control costs through the use of health alliances and budgetary caps...
...Single-payer health care would have firmly resolved the dilemma by saying that the health sector is a necessary social service and not an entrepreneurial haven...
...There are some problems in the exclusion of long-term care, mental health, drug and alcohol treatment, and there are unrealistic assumptions about treatment for people with serious and chronic problems...
...We must assure that poor people can get good, nondiscriminatory health care...
...Then more draconian rationers will come forward to provide care for the un-preferred consumers and will be seen as socially responsible for doing what no one else will...
...It is important to remember that the Reagan-Bush years were filled with denials of the health care crisis...
...In the United States, it is easy to pick the market niche that maximizes profits...
...A health care system that consumes 15 percent of gross domestic product, while leaving thirty-seven million people uninsured and fifty million people with inadequate insurance, is simply not a practical base upon which to create universal insurance...
...The barriers imposed by gatekeepers SPRING • 1994 • 199 Health Care Reform cannot be burdensome: health care reform must benefit not only young, educated people, but also overburdened, less articulate people with complex medical and social needs...
...This is the health system we really want...
...And health care is a small part of the industry's portfolio...
...Therefore, changes in the Clinton plan to weaken cost controls are simply unacceptable: they will create a health system that won't work...
...Every single-payer advocate who has met with Hillary Rodham Clinton or other leaders of the Health Care Reform Task Force reports their clear sympathy...
...While not elegant, they can be effective...
Vol. 41 • April 1994 • No. 2
