President Clinton's healthcare plan has been declared dead, buried and, perhaps worst of all, rejected by the general public, according to opinion polls.
But in the legislative arena, death is a relative term. It may be too soon to either mourn or celebrate the passing of the substance of the president's reform proposal, experts say.
The plan that's dead is one that Washington insiders never expected to survive: the entire Clinton bill, with all of its detail and policy initiatives. But Mr. Clinton's plan shares some features with nearly every one of the seven or so major reform proposals being introduced in Congress, so some of its central elements could be resurrected in a modified form as lawmakers craft a compromise bill.
"The Clinton plan, as written, is dead, but no plan is going to pass as written," said Michael Bromberg, executive director of the Federation of American Health Systems. "Its heart and soul are very much alive."
According to healthcare polling expert Robert Blendon, chairman of the department of health policy and management at the Harvard School of Public Health, "You can't look at public opinion polls and say the president's plan is dead. But a large number of people have concerns about the plan that are quite substantial."
Support questioned.Politically, questions surround the extent of support on Capitol Hill for most of the central elements of the president's plan.
Lawmakers from both parties have criticized the employer mandate, the primary financing vehicle for universal coverage in the Clinton proposal; premium caps, which administration officials have described as the "backstop" for cost containment, in case private-sector incentives to curb spending don't work; and mandatory health alliances, the state-based regional insurance purchasing groups, designed to bolster the purchasing clout of businesses and individuals.
Still, the House Ways and Means health subcommittee, the first congressional panel to take on the task of writing a healthcare reform bill, started with a modified version of the Clinton plan. Early in its deliberations, the panel affirmed support for the employer mandate, voting down a proposed Republican amendment that would have stripped the provision from the bill.
The subcommittee version, drafted by Rep. Fortney "Pete" Stark (D-Calif.), also includes a basic benefits package and a regulatory framework for controlling costs, as does the Clinton plan.
But in many ways, the proposals differ markedly. Mr. Stark's started out with no small-business subsidies, long-term-care coverage or mental health benefits, but the panel later amended the bill to add some subsidies or mental health coverage. The proposal includes a 0.8% payroll tax to fund a new government program for the unemployed, low-wage workers and current Medicaid recipients.
Other committees that will write legislation include House Education and Labor, Senate Labor and Human Resources, Senate Finance, and House Energy and Commerce.
The level of uncertainty in Congress is reflected in the more than 250 members who have signed multiple bills and those who have yet to support any plan.
A skittish public. The public, too, is uncommitted, although enthusiasm for the president's plan has waned measurably in polls. A March 14 poll by Time magazine found that 45% of the 600 Americans polled opposed the Clinton plan, while 41% favored it. Some 51% said it should be rejected or passed with major changes, and 70% said they thought it would cause their healthcare costs to increase. Mr. Blendon said those results mirror findings from other polls conducted at about the same time.
What's happening is that people are "struggling" to understand the Clinton bill, forming their opinions about it from "friends, neighbors, the press and ads," Mr. Blendon said. That's made it easier for opponents to raise doubts about the plan, he added.
The relentless criticism of the Clinton plan, which led to the erosion of popular support for it, has been "fueled by the fact that the administration presented something too complicated," said Lawrence Lewin, chairman and chief executive officer of Lewin-VHI, a Fairfax, Va.-based health research and consulting firm that analyzed the financial impact of the Clinton plan last year.
But while the plan "has been poorly sold and easily savaged," many features of the proposal are essential to achieving effective healthcare reform, Mr. Lewin said. Key proposals include the mandatory pooling of insurance risk, a requirement that employers and individuals buy insurance, and a standard benefits package, he said.
Bits and pieces.The originalproposal won't survive, but the question is whether "key pieces of it will be used as the basis" for a final bill, Mr. Lewin added.
For example, the plan's health alliances-regional purchasing groups through which all but the largest businesses and individuals would have to buy insurance-have been beaten to a pulp by Democrats and Republicans alike. Critics charge that they would be too bureaucratic, overly regulatory and that they would needlessly disrupt consumers' current healthcare arrangements.
Alliances became a prime target of the Health Insurance Association of America, which launched a $14 million ad campaign featuring "Harry and Louise" to fuel public fears that alliances would rob consumers of choice and impose giant government bureaucracies on the healthcare system.
According to a study commissioned by the Federation of American Health Systems, approximately 31,400 new government workers would be needed to staff the state-run alliances, at an annual cost of about $1.2 billion.
Support for the administration's brand of huge, mandatory purchasing groups has evaporated, in part because of the failure of the administration to effectively respond to the anxieties aroused by the HIAA blitz.
However, several congressional proposals include the creation of voluntary buying groups to help small businesses and individual purchasers pool their marketing clout. As a result, a less onerous version of the alliance could survive in the final bill, observers said.
"The alliance concept is not dead," Mr. Bromberg said.
The same is true for Medicare and Medicaid cuts, which total $124 billion over five years in the administration's bill. The cuts are, to varying degrees, key financing sources in even the most bare-bones reform proposal.
Making it universal.While the
1,344-page Clinton plan has hundreds of connected parts, the primary reform battle line has been drawn by the administration over universal coverage, and Congress' final reform bill will be shaped by whether and how it meets that goal.
Although lawmakers' have a self-imposed deadline of enacting reform legislation this year, they haven't begun to compromise on the positions they staked out long ago on this crucial issue.
Single-payer supporters, whose 92-member contingent in the House of Representatives hasn't diminished in number or fervor, favor a tax-financed approach to universal coverage, which would eliminate private insurers. Rep. Jim McDermott (D-Wash.), the lead sponsor of the House bill who's also a member of the Ways and Means health subcommittee, has vowed to take the single-payer measure all the way to the floor for a vote, regardless of which other bills are approved at the committee level.
Conservative Democrats, whose managed-competition proposal has 57 House supporters (26 of them Republicans), prefer a marketplace approach to achieving universal access through the implementation of insurance reforms and expanded public coverage for low-income Americans.
Rep. Michael Andrews (D-Texas), also a member of the Ways and Means health subcommittee, stuck to his guns and voted with Republicans on stripping the employer mandate from the health reform bill that members have been considering.
A group of 20 moderate Senate Republicans favor universal coverage through an individual mandate to purchase insurance, with federal subsidies for those with low incomes. Other Republican proposals are far less comprehensive, requiring individuals to buy catastrophic insurance coverage or creating medical savings accounts, while limiting cost and expanding access primarily through insurance market reforms.
President Clinton's reform plan, which has 131 congressional backers, would achieve universal coverage by requiring businesses to finance at least 80% of the cost of health insurance for their workers and providing federal subsidies to low-wage businesses and low-income Americans. In his State of the Union speech, he threatened to veto any legislation that flunked the basic test of guaranteed coverage for all, but he didn't specify how it must be achieved.
Settling for less.But as polls show
Americans growing increasingly concerned about the cost of reform, some observers said Congress and the president likely will settle for less than complete victory on universal coverage.
"Whatever passes, President Clinton will rightly claim credit that he has achieved comprehensive healthcare reform," said Frederick Graefe, a health lobbyist with the Washington law firm of Baker & Hostetler. The final bill will be a consensus plan that won't "break the bank," and will take "a long glide path to universal coverage," he added.
In light of the deep divisions on Capitol Hill, he predicted that lawmakers would take a minimalist approach to reform. For example, legislation that expands public coverage for the chronically uninsured and includes insurance reforms to enhance coverage for the working uninsured could greatly improve access and likely wouldn't have to clear impossible political hurdles, Mr. Graefe said.
"The guidepost for Congress this year is to do no harm," he said. "The American people want something done, but they want it limited and done very cautiously."
William Cox, vice president of government services for the Catholic Health Association, agreed that the public is sending a signal for elected officials to move slowly on reform. But he believes that rather than enact a less-than-comprehensive bill this year, Congress will delay action until next year.
"There just aren't any votes now that can be cast for anything in healthcare reform," he said. "I don't think (lawmakers) will reach agreement this year about how to finance universal coverage. "Significant obstacles have to be overcome in that area, not the least of which is, do we want to stick with an employer mandate?"
Mandate under attack.The president's proposed employer mandate has been under fire all year from small businesses, which historically haven't provided health insurance as an employee benefit, and by lawmakers on both sides of the political aisle. Opponents charge that the mandate potentially could cost hundreds of thousands of jobs.
Despite the controversy, many experts see an employer mandate as the most realistic option for achieving universal coverage and believe that it's one element of the Clinton plan that may survive, albeit in modified form.
"If we're not going to have a mandate, we might as well all go home," Mr. Stark said in a March 5 interview on CNN. "We are going to have to have some mandates on everybody, or we're going to have no law," Mr. Stark said.
At a recent briefing with reporters, American Hospital Association President Richard Davidson called an employer mandate "the least radical change" because it would be an extension of the current system. He suggested that lawmakers could compromise by shrinking the portion of insurance costs businesses would be required to pay, combining the employer mandate with an individual mandate and creating a sliding-scale contribution for small employers.
The mandate got a boost earlier this month in television ads sponsored by the Health Care Reform Project, a coalition of provider, consumer and labor groups, headed by John Rother, legislative director of the American Association of Retired Persons. The HCRP was formed to promote the framework of the Clinton plan. Although the AARP lacks sufficient grass-roots support to endorse the Clinton plan, the group has been instrumental in promoting its virtues.
The HCRP's ads touted the president's plan as one that would address Americans' key objectives for reform: It "guarantees affordable private insurance to everyone at work, whether you change jobs, get sick or work part time," one ad said. Another said the plan would outlaw insurance policy cancellations and benefit reductions when people get sick.
The ads, which cost $750,000, were designed "to inform Americans that the fundamental principles of reform they overwhelmingly support...are in fact embodied in the president's approach," Mr. Rother said in a statement when the ads were released.
Earlier this month, Sen. Tom Daschle (D-S.D.), a staunch defender of the president's plan, gathered signatures on a letter sent to all members of the House and Senate from 110 organizations-including the 100-member National Leadership Coalition for Health Care Reform-in support of an employer mandate.
The letter, signed by businesses, as well as labor, consumer and provider groups-including the American Hospital Association and Catholic Health Association-said a mandate is a "fair, effective and practical means for achieving universal coverage."
Sense of urgency.It's unclear whether there's enough time left for lawmakers to forge a compromise on a mandate that would satisfy those who believe it would harm large numbers of small businesses and wipe out jobs, as well as those who think it's the only viable route to universal coverage.
Nevertheless, a variety of political forces will pressure lawmakers, particularly Democrats, to stick to their timetable. With all House of Representatives seats and one-third of those in the Senate up for re-election this year, lawmakers will be anxious to enter the mid-term race with some type of healthcare reform legislation under their belts, experts said.
Moreover, the recent announcement by Senate Majority Leader George Mitchell (D-Maine) that he won't seek re-election sent shock waves through the Capitol and triggered a renewed sense of urgency to complete a reform bill this year.
Mr. Mitchell's lame-duck status is expected to diminish, if not eradicate, his ability to twist arms and cut deals as he shepherds reform through the Senate. Reform advocates hope he will muscle legislation through because of his sheer determination to make healthcare reform the crowning achievement of his Senate career.
The Whitewater wild card.An equally troublesome political roadblock could be the escalating Whitewater scandal, which at the very least will detract from the time and energy the president and first lady have to devote to building public support for reform.
For now, many political observers believe this could be a temporary setback with no political ramifications.
But "if it becomes so all-consuming, like Watergate, it would be an enormous distraction," said AHA's Mr. Davidson.
Furthermore, at a time when the president needs a strong political base to exert leadership on reform, the potential character stain of Whitewater could diminish that base.
But even as Republicans make political hay of the scandal, David Tell, spokesman for the conservative Project for the Republican Future, warned partisans not to rely on Whitewater to undermine the Clinton reform agenda.
"Healthcare reform has a momentum of its own," Mr. Tell said. "People whose political happiness depends on defeat of the Clinton health plan shouldn't breathe too deep a sigh of relief."