There was no refuge for President Clinton's healthcare plan last week as congressional Democrats ripped into the plan's health alliances, vowing to pursue their own version of reform.
Ira Magaziner, the president's senior health policy adviser, told an audience at last week's American College of Healthcare Executives meeting in Chicago that the administration's reform plan would hit several "land mines" as it made its way through Congress, but it ultimately would prevail.
The relentless assault on the plan, especially from within the president's own party, has heightened doubts about Congress' ability to meet an ambitious schedule for completing action on a reform plan this year, and about lawmakers' ability to reach a workable agreement on a bill.
"There is no consensus in Congress, anywhere," said Michael Bromberg, executive director of the Federation of American Health Systems. "And there doesn't seem to be a mechanism for bringing these views together."
The House Ways and Means Committee's health subcommittee is scheduled to start writing its version of reform legislation this week. Rep. Fortney "Pete" Stark (D-Calif.), chairman of the panel, already has said that the legislation will be only loosely based on the president's reform plan and won't include mandatory health alliances. Under the plan, alliances are giant regional purchasing groups that would be in charge of collecting insurance premiums and buying coverage for most Americans.
An aide to Mr. Stark said subcommittee members had been meeting to try to reach agreement on a starting point for a bill, which may be difficult for a panel whose Democratic members run the ideological gamut from single-payer supporters seeking a government-run system to conservative Democrats who prefer market-driven changes.
One of the main reasons Mr. Stark and others already have rejected health alliances was their conclusion that they would needlessly disrupt current insurance arrangements of individuals who were satisfied with their coverage, the aide said.
Mr. Stark's office, as well as those of other lawmakers, have been flooded with constituent mail complaining about the scope of the president's health plan.
"Just correct problems in the current system," the aide said, reading from one of the letters. "We don't need alliances."
"Constituents are very scared. This could be (like) Medicare catastrophic if we're not careful," the aide said, referring to the public backlash that led to the quick repeal of legislation that extended Medicare coverage to catastrophic illnesses.
The subcommittee is waiting for estimates on various policy options from the Congressional Budget Office. But it's likely that the bill the panel starts with will achieve the goal of universal coverage, with some form of contribution from employers and new programs to cover the uninsured, aides to Mr. Stark said. But there will be no health alliances in the bill.
"It's clear that alliances are not popular with anybody," said Mr. Bromberg, who like many health executives supports voluntary purchasing groups for small businesses and individuals.
Richard Wade, the American Hospital Association's senior vice president for communications, said some form of alliances inevitably would be part of a reformed healthcare system.
Alliances are going to be a "necessary component of reform, whether they come from the federal level" or are localized, Mr. Wade said. "They will never be dead." What has been dashed on the rocks, though, is the brand of alliances envisioned in the president's plan, he added.
"Big alliances with broad regulatory authority that everyone has to be in, those are clearly not going to be part of the final outcome," he said.
A group of leading Senate Democrats held a press briefing on the eve of a Senate Finance Committee hearing on alliances to defend them as the most efficient way to collect premiums and put purchasing power in the hands of consumers. At the hearing, Sen. John D. Rockefeller (D-W.Va.) said efforts to promote voluntary over mandatory alliances were a "dodge" on the part of opponents who wanted to slow or kill healthcare reform.
Nevertheless, the White House last week appeared to concede defeat. Asked at a press conference how the president would respond to a reform bill that excluded alliances, White House Press Secretary Dee Dee Myers said: "If the Congress comes up with a plan that meets the president's objective, which is guaranteed private insurance for every American, he'll sign it."
In an effort to advance a consensus, Mr. Clinton courted some key lawmakers last week, meeting with Senate leaders and a group of House members who support single-payer legislation.
Sen. Bob Packwood (R-Ore.) said at a hearing later in the week that after his meeting with the president, he was confident that the Senate could produce a bill-minus mandatory health alliances-that would achieve universal coverage and garner 70 votes.
But Rep. Jim McDermott (D-Wash.), chief sponsor of the House's single-payer plan, was less conciliatory following his meeting with the president. Single-payer backers told the president "they will continue to press for passage of their own plan and warned the president they will vote against any package that compromises on the issues of universal health insurance coverage," said a statement from Mr. McDermott's office.
"I think the president understands he cannot pass any version of health reform without our votes, and that he is not going to get our votes by simply making more compromises with those who do not share his basic goal of universal health insurance coverage," Mr. McDermott said. He said that while the group will continue to work on smoothing differences with the White House, there were many serious disagreements, and the president shouldn't "continue to think our votes are in his column."
The administration kept at least one powerful ally in its corner last week. Despite the bruising battle over the North American Free Trade Agreement, the AFL-CIO restated its commitment to invest heavily in promoting the president's healthcare reform plan.
Union leaders meeting in Bal Harbour, Fla., said they would spend "at least as much as we did trying to defeat NAFTA"-an amount estimated at more than $3 million-for ads in support of the president's health plan.
Including time, personnel and other resources, the unions intend to commit as much as $10 million and will "campaign as hard as we can for as long as it takes," said AFL-CIO President Lane Kirkland.
At the ACHE meeting, Mr. Magaziner predicted that public demand would drive the eventual enactment of healthcare reform legislation. Citing polls that consistently show a majority of Americans support Mr. Clinton's efforts, he said that would be the "driving force behind this."
The ACHE made its contribution to the debate, endorsing broad criteria for reform, including: universal access to basic healthcare services, with an emphasis on prevention; provider reimbursement levels that match individuals' health needs; consumer choice and responsibility; reducing excess capacity in the health system; and improving quality through the use of outcome measures.