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THE NATION : HEALTH CARE

Enemy Is Bureaucrats, HMO or Feds

July 12, 1998|William Schneider | William Schneider, a contributing editor to Opinion, is a political analyst for CNN

WASHINGTON — Remember the debate over health-care reform four years ago? It's back. Actually, it never really went away. Just as many people think the health-care system is in crisis now--about 40%, according to last week's Gallup poll--as thought that in 1994.

Four years ago, the crisis was driven by people's fear of losing their health insurance if they lost their jobs. Today, people's jobs are more secure. So what's driving this crisis? Essentially, the same thing as in 1994: fear of bureaucratic rationing. But this time, the bureaucrats are private, not public.

Most Americans don't see much of a difference. But it makes a big difference politically. Now Republicans have to worry about being in the same unhappy position Democrats were in four years ago, namely, defending bureaucratic intrusion in the health-care system.

There's one big difference between 1994 and 1998: Most Americans are now in managed-care plans. They're worried about their rights. The biggest applause line in President Bill Clinton's State of the Union speech in January came when he said, "I urge this Congress to reach across the aisle and write into law a consumer bill of rights that says this: You have the right to know all your medical options, not just the cheapest. You have the right to choose the doctor you want for the care you need."

Are people in managed care unhappy with the quality of their medical care? Actually, no. Seven of eight told Gallup they were satisfied. Not very satisfied, mind you. Just 39% said that, compared with 59% of people in traditional fee-for-service plans, where there are no restrictions on choice.

Why the difference? Most people in managed care have not had bad experiences, like having their insurance company overrule their doctor. Fourteen percent of people in managed care say that's happened to them or to someone in their family. That compares with 9% of people in traditional plans. Have they been denied medical treatment they thought was necessary? That has happened to 12% of people in managed care and 7% of people in traditional plans.

Do people in managed care want to change to another type of plan? Most say "no." Would they recommend their health-care plan to someone else? More than two-thirds say "yes." Nonetheless, people in both kinds of plans agree: A fee-for-service plan in which you can go to any doctor you choose is better than a managed-care plan.

Remember the scene in the movie "As Good As It Gets," when the mother with the asthmatic son complains to a private physician about her son not getting the proper medical tests: "Those *#!*# HMO bastards! They said they weren't covered under my plan and weren't necessary!" When she apologizes for her language, the physician responds, "That's all right. I think that's actually their technical name." Audiences all over the country applauded.

What's creating public anxiety is the basic concept of managed care: that a bureaucrat can control your health care. As Democratic pollster Mark Mellman put it, "The public sees somebody 2,500 miles away in some insurance company or health-care plan, sitting behind a computer terminal, telling their doctor what treatments and tests that doctor can use, what medicines the doctor can prescribe, and the public says, 'Enough of that.' "

Americans don't like bureaucratic rationing. That's why gasoline lines were such a bitter experience in the 1970s. In this country, it's much easier to ration things by price. When people were told they had to wait in line for gasoline, or fill up only on odd or even days, or leave their cars at home certain days, we almost had a revolution. How did the problem get solved? The price of gasoline went up. Sure, people complained about having to pay a dollar a gallon for gas. But it was better than waiting in line.

Health care has always been rationed by price, too. If you have more money, you can buy better care. Do Americans think that's fair? Of course not. In fact, 69% believe the federal government should guarantee health care for all Americans, about the same as in 1994. But when the Clinton administration tried to turn that view into a mandate for health-care reform, the public balked. They were afraid Hillary Rodham Clinton's 1,510-page health-care plan would give the government too much control.

Americans didn't want government bureaucrats to come between them and their doctors. That is, of course, exactly what happens with Medicare, the most popular government program after Social Security. But for most Americans younger than 65, government rationing of health care is frightening and unfamiliar. The Health Insurance Assn. of America saw to that by running the "Harry and Louise" ads.

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