WASHINGTON — As the Senate launched its long-awaited health care debate this week, Majority Leader George J. Mitchell (D-Me.) declared that the American health care system is mired in "a crisis of affordability and price."
Yet, ironically, the issue of containing health care costs has receded into the background of the discussion, almost drowned out by the far louder argument over universal coverage.
From the start, President Clinton and his allies have argued that universal coverage and cost containment are the interlocking parts of the health reform jigsaw puzzle. As long as large numbers of people remain uninsured, the costs of their treatment will continue to be paid indirectly by those who have coverage.
But the prospects for achieving universal coverage in the near future look increasingly bleak. And as congressional leaders struggle to hold the line in that arena, they are being forced to make concessions that erode cost-containment efforts in other areas.
Cost was the issue that got the entire health care debate going. America now spends 14% of its gross domestic product on medical care, a far greater share than any other country. As costs have soared, workers with coverage have been forced to forgo wage increases to pay for them and the consequences of being uninsured have grown to sometimes tragic proportions.
The President's original approach to reining in costs, which included a form of government cost controls, was rejected early on by Congress. But the proposals that have replaced it in the major alternatives now before both houses are far from certain to do the trick.
The reason for the shift in emphasis, said Brookings Institution analyst Henry Aaron, is as simple as this: "Universal coverage brings joy. Cost containment inflicts pain."
"Politically, there is absolutely no mileage in cost control," agreed Uwe Reinhardt, a health expert at Princeton University.
Congressional leaders have inserted provisions in both plans that actually could undermine some of the cost restraint that already is going on in the health care market today.
"On the one hand, they're saying we can't have price controls. On the other, they're removing the ability of the market to control costs. . . . Most proposals have really been at cross purposes," said Bill Custer, research director of the Employee Benefits Research Institute, a private, nonprofit public policy research organization in Washington.
As a result, he said, the legislation that Congress ultimately produces--if, in fact, it produces any--might actually make health spending increase faster than it otherwise would have because more people would be using the system without any incentive to decrease costs.
As recently as this week, when an ABC News poll asked which was the more important goal of health reform, 49% said it was holding down costs, edging out the 45% who chose insurance for all. But while bringing down health care costs sounds good in principle, actually doing it is another matter entirely. That is because:
* Cost containment almost certainly means limiting consumer choice. Health maintenance organizations, for instance, have managed to bring down their costs by limiting the network of doctors and hospitals with which they do business.
However, the House Democratic leadership bill undercuts their ability to do that with the "any willing provider" provision, which requires networks to admit any qualified physician who is willing to accept their rates. Both bills also offer what critics consider overly broad definitions of the "essential community providers," such as hospitals, clinics and medical professionals, with which the networks are required to contract. Moreover, the bills require companies to offer their workers at least one plan with unlimited choice of doctors, an option that is generally more expensive.
* The urgency has faded as the increase in health premium prices has slowed from double-digit levels in the late-1980s to single-digit figures now. In some areas, premiums are even going down. But some analysts say that health inflation could easily reignite, once the threat of restrictive legislation is gone.
* Most consumers are insulated somewhat from the true cost of their care because their employers pay all or part of their premiums. Proposals to shift more of the true cost to the actual users of medical care--by making health premiums part of their taxable income, for instance--have been dropped by congressional committees in the face of stiff opposition.
* Cutting costs means curbing the earnings of doctors, hospitals, drug companies and medical technology firms--all of whom employ powerful lobbies in Washington.