The Rhetoric and the Reality of Health Care Reform Legislation. 6th Annual Herbert Lourie Memorial Lecture on Health Policy

A plethora of political autopsies have been performed on the Clinton Administration's failed health care reform of 1994--it was too much; it was too late; there was too much pandering; there was too little pandering. Such critiques of this complex undertaking are at least partially correct. It was probably hubris to believe that such a comprehensive health care reform package could be proposed and passed in a single year. But much of the instant analysis of its failure has repeated the rhetoric of the debate rather than stepping back and placing the events of 1994 in perspective. Here I focus on five areas where rhetoric confused the debate, and compare them with the underlying realities of health care reform: (1) Financing. Proponents of the Administration proposal argued that universal coverage could be achieved primarily by redirecting existing revenue flows. It offered almost no new revenue sources--aside from a "sin tax" on tobacco. The reality is that to achieve universal coverage, we all have to pay for it, either directly or indirectly. And indirect payments can cause serious problems. (2) Controlling Costs. In an attempt to make cost containment efforts seem less onerous on individuals, the rhetoric offered two somewhat contradictory strategies of imposing *price controls* on health care providers and introducing market reforms, called *managed competition*. Presumably, managed competition would also automatically eliminate fraud, waste, and abuse, and in some unspecified way painlessly discipline the market for health care. The reality is tht people must face difficult choices if we are to control the costs of health care. Cost containment is a much more controversial issue than the Administration admitted. Many persons are nervous about the impacts of such controls. (3) Choice. The Administration went out of its way to promise choice, often in ways that complicated the plan. Opponents countered that the Administration's plan would actually limit choice. But what did they mean by choice? If they meant choice of doctors and hospitals, or choice of insurance plans, the Administration's plan stacked up very well. But the right to choose any kind of health care at any time would have been restricted under the Clinton proposal. Moreover, choice has long been eroding for most Americans as employers and insurance companies have imposed more control on insurance. In this case, the rhetoric of the opponents won out over the reality of what is already happening in our health care system. (4) Incremental Reform. Opponents of the Administration's proposal claimed that successful health care reform could be achieved by "tinkering around the edges," keeping what was right about the health care system and getting rid of what was wrong. The reality is that changes in one area of health care provision affect other areas, in ways that are not always understood or anticipated, and there is little consensus on what should be kept and what should be changed under an incremental approach. (5) Nostalgia. Many of those who opposed health care reform altogether expressed a longing to return to a health care system that they remember and think still exists, but that probably hasn't been in place for the last decade. Their warning that we should not surrender what we have for something less was given more credence than the Administration and other reformers realized. The reality is that health care has already changed rapidly and will continue to change with or without health care reform legislation. The Clinton Administration assumed that Americans understood the current status of national health care, including its flaws, and assumed this meant they had a mandate for change.