If we have learned anything from the health reform debates of the past five years, it's that no proposed change, however small, is easy and uncomplicated.
That's why some Republicans on Capitol Hill and business executives recently felt a wave of fear and loathing when Senate Majority Leader Trent Lott (R-Miss.) addressed the subject of healthcare reform. He indicated that the GOP would not be outflanked on the issue and would instead take what management types call a proactive stance.
Swiping a page from the White House political playbook ("No good plan should go unfilched"), Lott said GOP leaders would devise their own plan in 1997 for expanding access to care for children.
They intercepted a pass from President Clinton, who called for such a measure during the Democratic National Convention last August.
But hold on, say some members of the Grand Old Party. This "incremental" health reform stuff is not nearly as simple as it seems. As evidence, they cite the health insurance reform bill passed last year by Congress.
When bipartisan health insurance reform finally won passage last year, one of its Senate co-sponsors, Nancy L. Kassebaum (R-Kan.), hailed it as a "good first step"-meaning incremental, even marginal changes.
But now, six months after the president signed Kassebaum-Kennedy into law-he also called it a good first step-and nearly a month after some of the provisions took effect, a different picture is forming. It's becoming clear that the only person who could regard the health insurance bill as easy to digest is White House health policy guru Ira Magaziner, who also contended the Rube Goldberg Clinton health reform plan was simple.
At a recent meeting sponsored by the National Association of Insurance Commissioners, state legislators grilled HCFA Administrator Bruce Vladeck about changes the states will have to make to ensure compliance with the new federal rules.
For example, many states already have high-risk insurance pools. The new bill lists high-risk pools as one of the options available to states to allow individuals who lose their employer-sponsored health insurance plan to buy individual policies, as mandated by the law. Now, the states that have such pools must make changes to bring them into compliance with the federal law.
Of course, the federal government has not even released the regulations that will give states the details of what is required.
Vladeck told the state lawmakers that HCFA would review the situation and give a state leeway if it were found to be "substantially in compliance" with the new law.
That did little to appease the states.
"This is going to be a tougher task than we expected," said a gubernatorial aide who asked not to be identified. "This means more state change than we were originally led to believe."
There are other provisions of the Kassebaum-Kennedy bill that are equally complicated, regulatory and regressive.
For example, the bill included a wide-ranging set of Medicare/Medicaid fraud-and-abuse rules. Under the bill, HCFA was required to begin seeking input on regulations to implement the new rules within 45 days of enactment of the legislation.
But according to several industry sources who have a vested interest in the process, the talks have yet to begin.
"This is much, much more than people had anticipated," said Heidi Wagner Hayduk, a McLean, Va., consultant who deals with issues of privacy, administrative simplification, and fraud and abuse.
So what does that mean for any health reform plans that might be considered this year?
It means that to overcome Republican reluctance in Congress, a proposal is going to have to be straightforward and truly modest. Unfortunately, as the experience with the "incremental" Kassebaum-Kennedy measure proves, increasing access to care is rarely simple.
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The American Medical Association caused a stir among other special interest groups in Washington last month with the release of its Medicare reform plan.
The plan contains little that is innovative or controversial: It calls for Medicare to be transformed into a defined contribution plan. That's similar to provisions of budget legislation passed by Congress last year and vetoed by Clinton.
What caused the stir was the way the plan would distribute what most people assume is a shrinking Medicare pie.
The proposal calls for physician Medicare reimbursements to grow at a rate equal to the increase in the gross domestic product plus four percentage points.
That is two percentage points higher than the Republican plan in 1995 and three percentage points higher than the last White House budget.
Needless to say, if the total Medicare pie is being reduced to balance the budget, giving physicians a bigger slice means less for hospitals and managed-care plans.
And that's not all, folks.
The plan also would end the era of physician fees being set by Medicare. Instead, doctors would be allowed to name their own fees, and consumers would be free to select whomever they want using price as a guide if they wish. It's a return to unvarnished fee-for-service medicine.
The AMA calls this scheme "competitive pricing." Those less charitably inclined might describe it as "competitive consumer confusion" or, perhaps, "monopoly."
Insurers have their own reasons to be crabby about the AMA plan. It would eliminate Medicare supplemental insurance policies in favor of something like a medical savings account, with payouts going directly to the provider.
The plan also would take money from a variety of other programs and channel it directly to physicians. Graduate medical education payments, for instance, would be distributed through vouchers given to individuals, not institutions.
But don't worry about the AMA proposal, America. It's only incremental reform.