Analysts Recommend Lower Health Care Reform
Pear, Robert, THE JOURNAL RECORD
N.Y. Times News Service
WASHINGTON _ Health policy experts, including many who advised Bill Clinton over the last two years, say he and Congress should set their sights lower, worry less about the goal of universal health insurance and try to make modest improvements in the nation's health care system next year.
They say two issues are likely to dominate the health policy agenda of the next Congress: Proposals to curb the growth of Medicare and Medicaid. Proposals to give states more freedom to pursue their own health care plans.
These issues are only pieces of the national health care debate, but they are big pieces. Medicare and Medicaid account for the bulk of federal health spending, costs that are rising fast. And with the collapse of President Clinton's health care plan and of all efforts to guarantee health insurance at the federal level, states are clamoring for more authority to tax and regulate the health benefits provided by companies operating within their borders.
Large multistate corporations, whose health plans are now generally exempt from such state regulation, say they will resist efforts to give states more flexibility under federal law.
Regardless of the results of the Nov. 8 elections, and regardless of what Clinton might propose, the national debate over health care will continue simply because 39 million Americans still lack coverage and health costs are still rising much faster than other consumer prices.
But Drew E. Altman, president of the Henry J. Kaiser Family Foundation, which studies health policy, said, "For health reform to succeed in the next Congress, it must be simpler, less scary, less bureaucratic _ a more incremental plan, in bite-size chunks."
One area with obvious political appeal is legislation to assure health care for children.
Altman predicted that "there will be a huge debate about caps and cuts in Medicare and Medicaid, driven by a desire for reduction of the federal budget deficit, not by a desire to pay for expanded coverage." And "while states can do very significant health care reform," he said, "there are real limits to what they can do without getting exemptions from federal laws" like the Employee Retirement Income Security Act, known as ERISA.
One purpose of that law, passed in 1974, was to establish a comprehensive, uniform federal system to regulate pension and health plans so they would not be subject to conflicting state requirements. But now Minnesota, Oregon, Washington, Maryland and other states say they need exemptions from ERISA so they can carry out ambitious plans to expand insurance coverage and control health costs.
"State flexibility will be a big issue next year," said Sen. Paul Wellstone, D-Minn. "In Congress, you'll see a major effort to permit greater state flexibility."
Wellstone wants to let states try Canadian-style "single payer" programs of health care financed with taxes. Several states want to require all employers to buy or provide a standard package of health benefits for employees.
Surveying the wreckage of health care legislation on Capitol Hill, many experts said future proposals must rely less on federal authority and more on market forces already revolutionizing the delivery of health care in the United States.
As a presidential candidate in 1992 and for a while after his inauguration, Clinton supported the idea of "managed competition," which combines market forces with government regulation in the hope that doctors and hospitals will compete for business on the basis of price and quality.
The originators of that idea, far from being distraught over the rejection of the Clinton plan, feel partly vindicated.
"Our horse didn't cross the finish line," said Alain C. Enthoven, a professor at Stanford University who is the intellectual father of managed competition. …