When the healthcare reform debate began in earnest last year, countless hours were devoted to the question of whether it was better to repair the healthcare system in one sweep or to take small steps over several years.
Now, after months of congressional whittling, the debate is about whether to tackle some small steps or do nothing at all.
Theoretically, nearly a dozen healthcare reform plans still are alive in Congress. But as a practical matter, the only ones that still have any vitality are the incremental plans of the Senate "mainstream coalition," the House plan developed by Reps. J. Roy Rowland (D-Ga.) and Michael Bilirakis (R-Fla.), and the "Kidcare" plan being developed by Senate liberals.
The question before Congress is, can one of those plans, or a variation on the theme, do the following:
Avoid the many congressional land mines.
Help control costs and reduce the number of uninsured.
Avoid sabotaging reform efforts taking place in the states and in the private market.
The effort will be complicated by the fact that there are perhaps fewer than 20 days left in the legislative year.
"I think, given this late date, (Congress) should pull the plug and not try to rush it. If they do rush things through, I think it's going to be a lose-lose situation for not only the hospitals but patients as well."
-Bob Houser, chief executive officer, Winner (S.D.) Regional Healthcare Center
When the Clinton administration unveiled its healthcare plan in late 1993, even its supporters realized its complexity was fodder for critics.
As the release of the Clinton plan was delayed month to month, opponents readied their attacks. Employers fought the mandatory health alliances, providers criticized the global budgets, and insurers said the plan was government-run healthcare.
As expected, financing the plan became the hottest issue. Employers viewed the mandate that they provide coverage as a tax in disguise. Providers said the Medicare cuts were too severe, and representatives from Southern states vowed to fight proposals for a hefty tobacco tax.
As time passed, members of Congress, believing that if they eliminated those controversial provisions support for reform would grow, developed various incremental plans. But a curious thing also happened. As the bills got smaller, so did the universe of healthcare reform advocates.
Providers are about equally split on the issue of whether an incremental plan will do more harm than good. But all are concerned that Congress will pass a plan that includes significant Medicare spending reductions without any real movement toward universal coverage.
"The Rowland-Bilirakis and mainstream coalition proposals call for steep cuts in federal spending ....Furthermore, the half-loaf proposals fail to address crucial public health issues such as AIDS," said Daniel Sisto, president of the Healthcare Association of New York State. "In short, these limited reforms are worse than no reform at all."
Employers and insurers are very squeamish about an incremental plan, which they say would increase healthcare costs paid by employers. They argued, for example, that community rating-in which premiums are based on an entire population-would increase insurance costs for younger workers, giving them incentive to drop their insurance. This would leave only older, sicker workers in the insurance pool.
"The bottom line is that a bad bill is far worse than no bill," a coalition of nearly 40 business associations told Congress recently.
And, perhaps most significantly, Congress is losing some supporters of the Clinton plan, primarily senior citizens and consumer groups, which have come out against the incremental plans.
"Senior citizens are going to be the big losers under these (incremental) plans," said Ronald Pollack, executive director of Families USA, a consumer group. "They all include huge Medicare cutbacks, and the revenues are taken for deficit reduction. If that continues to be the case, then I think there is going to be a huge coalescing against incremental reform."
The opposition to incremental reform leaves Congress in a position it doesn't like to assume: trying to pass a program that does not have a clear base of support.
"I don't think the political constituency is there to pass healthcare reform right now," said Richard Pollack, executive vice president of federal relations at the American Hospital Association.
"To try to hurry up and do something is a mistake. Reform is something that has to be studied. It can't be an emotional issue. It can't be tied to an election."
-Bill Seek, CEO, Jefferson Memorial Hospital, Crystal City, Mo.
Recent polls have shown that the American public thinks Congress should put healthcare reform off until next year, a clear indication that confusion reigns.
When Senate Majority Leader George Mitchell (D-Maine) sent the Senate home for a two-week recess, he knew he was taking a gamble. If members came back with a feeling that the public was more scared of healthcare reform than it was of no action, the prospects for reform would take another hit.
According to several staff members, what happened when senators went home was nothing.
"No one was really talking about healthcare reform," said one staffer who asked not to be identified. "Crime, government-those were the issues. Healthcare was yesterday's news."
Without a strong flame under the congressional pot, there is very little reason for members of Congress to go out on a limb for healthcare reform, observers say.
"I think the fear of doing something unpopular outweighs the fear of doing nothing," said the AHA's Mr. Pollack.
"(President) Clinton needs something so badly, I think he'll hang his hat on anything Congress puts on his desk."
-Steve Brenton, president of the Iowa Hospital Association
For months, Congress has been schizophrenic about the Clinton administration and healthcare reform. Democratic leaders in the House and Senate one day would say the president was not providing enough leadership; the next day he was meddling too much.
But with so little time remaining, it's obvious the process needs a kick and that Mr. Clinton is the only one with a foot nearly big enough.
So far, that hasn't been forthcoming, observers said.
"The president just isn't engaged," said Michael Bromberg, executive director of the Federation of American Health Systems. "Saying, `If you send me something I will look at it,' that kind of leadership is not going to get it done."
"The massive reform programs contemplated so far need such major changes and correction that there doesn't seem to be enough time left for this Congress to act."
-Dennis Hall, president and CEO, Baptist Health System, Birmingham, Ala.
So, with Congress hearing a steady drumbeat against incremental reform, the American public worried and increasingly apathetic, and the president's attention turned to other things, what are the chances for reform?
Not very good, say provider representatives.
Mr. Bromberg said there was a 20% chance that Congress would act this year. "But it's getting smaller all the time," he added.
Others were less optimistic.
"We still hope to get something that is at least the start of universal coverage. But, at this point, I don't see how they can get healthcare done this year," said Charles Huntington, director of the Washington office of the American Academy of Family Physicians.
Over the past 18 months, dozens of plans, beginning with the president's 2,000-page tome, have been introduced and circulated as written documents.
Laura Allendorf, director of congressional affairs for the American Society of Internal Medicine, looked back and lamented that "so many trees gave their lives, just to end up with nothing."