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PERSPECTIVE ON HEALTH-CARE REFORM : Rx for Recovery--Next Year : The public still wants a plan, but it has to be concise, honest and gimmick-free--a task for the new Congress.

October 09, 1994|THEODORE R. MARMOR and MARK GOLDBERG | Theodore R. Marmor is a professor of public policy at Yale School of Management and author of "Understanding Health Care Reform" (Yale University Press, 1994 ) . Mark Goldberg, a management fellow at Yale University, is the editor of the magazine Domestic Affairs.

During the last week of September, Senate Majority Leader George Mitchell officially declared what had been evident for weeks: For health care reform, the future is not now.

Recriminations have already begun in earnest. But more important than assigning blame--of which there is more than enough to distribute--is drawing sensible lessons for the future. After all, the problems health-care reform was supposed to address--escalating costs and eroding coverage--have not suddenly disappeared.

There are at least three schools of thought about the near-term future of reform.

One view is that reform is dead, not just for this session of Congress but for the foreseeable future. Yet public support for reform, as distinguished from support for particular proposals (such as the Clinton bill), continues to be widespread.

A Congress that is acutely sensitive to constituency concerns would be politically ill-advised, and hence unlikely, to walk away from health care altogether.

Another school of thought arises from September's frenzied, last-minute negotiations over various versions of incremental (i.e. less ambitious) reform. These discussions, it is claimed, provide a good base from which to proceed in the next session of Congress.

But whether "lite reform" is an accurate forecast, it is a poor policy prescription. The packages put together in September were improvisations made under pressure. They were not remedies equal to the problems they purported to solve. For example, the plan floated by the self-styled mainstream coalition in the Senate had no credible controls of costs and no pretension of achieving anything remotely resembling universal coverage.

All of which leads us to a more sensible prescription: start over. This does not mean beginning with an entirely clean slate. Congress has surely learned something about which policies are workable and politically plausible and which are not. It is, for example, not likely that there will be a groundswell of congressional support for the Clinton bill's particular brand of health alliances. Yet, if the public demand for major reform persists and American medicine's problems remain enormous, inaction or marginalism will not satisfy. What Congress will have to do is regroup and devise a new strategy to take on the big problems.

The debate just past provides some clues about what form that strategy should take. It should be simple and straightforward. Of the six principles the Administration's proposal was said to embody, the one it clearly fell far short on was simplicity. If a member of Congress can't readily understand a bill and explain it to constituents, it fails as a prescription.

Reform should deal with coverage and cost concurrently, and be presented as such. Because of cost-shifting, it is enormously difficult to restrain medical inflation without universal coverage. Because of the realities of federal budget-making and breaking, it is practically impossible to achieve universal coverage without effective restraints on cost. Besides, combining universal coverage and cost containment in one bill can bring together those who very much want one or the other. It was clearly a mistake for the Clinton Administration to have focused its rhetoric on universal coverage alone this past summer. The Clinton bill never got the credit its strong cost-containment provisions actually deserved, and as a result never got as much support as it otherwise might have gathered within the business community.

Another lesson is that reform should include clearly understandable financing. Playing games with smoke and mirrors is not credible public finance. Subsidies for employers and families cost money. Everybody knows that and polls have consistently shown the public willing to pay something extra for permanent health coverage. Gimmicks of structure and labels do not fool the public for long. Verbal masking of undeniable truths breeds cynicism about politics and about health-care reform. It also helps to defeat incumbents.

None of this suggests that reforming American medical care will be easier next year than it was this year. But, as with the Olympics, degree of difficulty matters. Congress should aim high before forsaking effective reform for mere palliatives. Episodes of legislative stalemate, as the struggle over civil rights and Medicare showed in the 1960s, need not mean political defeat or need not frustrate later reform.

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