When Robert Reischauer, chief of the Congressional Budget Office, met with a group of healthcare reporters in Washington a couple of months ago, he warned that lawmakers have to "take care that what emerges (from the reform debate) is coherent....Crafting a healthcare reform bill is unlike anything Congress has ever done before." He then added, "Health reform is different in that it has to be a single integrated whole....You can't do it piece by piece. And you can't rush the process."
While congressional committees and leaders usually pay close attention to Mr. Reischauer's opinions, this time no one appears to be listening. In the highly politicized rush to enact a national healthcare financing system, lawmakers are improvising almost by the day. There are nearly as many viewpoints as there are pressure groups and members of Congress. What may be headed toward enactment is a changing package of provisions, all designed to please, or not to displease, certain powerful constituencies.
Compromising position. Should the House and Senate finally pass a reform plan, it will be a product of the many compromises now taking place. Then, what results from a House-Senate conference to resolve differences in their bills will be compromises on compromises. In other words, prospects are dim for passage of a thought-through program, which most sponsors of the original bills had in mind.
Initially, the Clinton administration fashioned a patchwork of its own compromises following leaks from the closed-door deliberations of Hillary Rodham Clinton's drafting committee. The leaks produced considerable negative reactions, prompting changes in the draft before it was made public. But the president's bill was still more or less a plan with all the pieces put together.
Other offerings-such as the Republican alternative from Sen. John Chafee (R-R.I.), the managed-competition approach sponsored by Rep. Jim Cooper (D-Tenn.) and several versions of Canadian-style, single-payer bills-also claimed to be complete, although Mr. Cooper's plan was criticized for lacking a comprehensive financing mechanism.
Making change.For the past several weeks, congressional committees, under intense political pressure, have been making frequent changes in the plans under their jurisdiction. One day a plan is employer-financed; the next day it's an individual mandate; then it's neither. The methods of financing a changeable list of benefits have varied widely, including "sin" taxes and slashes in the Medicare and Medicaid programs.
Predicting what is likely to emerge is taking on the character of betting on a roulette wheel. Veteran Washington observers are having nightmares about what would happen if a patchwork form of such a huge program-affecting nearly every American-is sent to the White House, where the president may or may not sign it.
The president himself added to the confusion when he appeared to back off on his original demand for universal coverage. Recognizing that, administration officials frantically sought to reassure Congress that he was doing no such thing.
Catastrophic lesson. The situation reminds some, on a lesser scale, of what happened when the Reagan administration unveiled its plan for catastrophic health insurance in 1987. As the plan wended its way through Congress, changes began to appear, particularly in its financing. At a point very late in the game the next year, lawmakers added a method of progressive financing to fund tacked-on benefits such as outpatient prescription drugs. To pay for the program, the final version of the bill contained a surtax for seniors with income above a certain level. It was this new tax that shocked the taxable elderly after an opportunistic organization used the issue to frighten the nation's seniors in a scheme to enlarge its membership and take advantage of the resulting power base.
As history shows, the scheme worked so well that Congress repealed the catastrophic program in fear of retaliation by angry voters. The seniors' reaction was so powerful that lawmakers couldn't scuttle the program fast enough.
Actually, the original catastrophic bill was relatively simple and was widely publicized. It was the last-minute changes dropped on an unsuspecting public that caused the angry reaction.
"Congress took two full years on catastrophic," said John Rother, legislative director of the American Association of Retired Persons. "But it got rushed through. If Congress would now just choose an approach (in the current healthcare reform debate) and use it."
In the current reform situation, the bills being considered and frequently revamped are anything but simple. Mr. Reischauer and others worry that not only will the final, complex program be unfamiliar to many, but that because of the reactive changes, it just won't work. They also fear it won't provide an effective answer to a national problem this country has faced for many years-millions of uninsured Americans. Most people thought such a solution was finally just around the corner.