Let's Play Doctor
Politicians of both parties say managed care is an increasingly
hot issue. The question now: Will they just fight over it or
actually try to do something?
By Karen Tumulty
You have probably never heard of Robert A. Bonifas, but you may be seeing a lot of him in the next few months. Bonifas, the owner of an Aurora, Ill., burglar-alarm company, is the star of a 30-sec. spot that the HMO industry is considering rolling out across the U.S. this summer to keep Congress from imposing new regulations on them in a burst of election-year populism. "We work hard to make people safer, and we work hard to offer our employees health insurance," Bonifas says in rich Middle American earnestness. "Higher health-insurance costs may not be a big deal to some politicians, but to our employees and their families, it's a very big deal." The camera scans Bonifas and his office of contented, healthy workers, toiling away as a message on the screen warns that Washington could leave 2 million people like them without health insurance. "When politicians play doctor," a voice concludes, "real people can get hurt."
So can politicians. In 1994 President Clinton learned what happens when government tries to do too much, and almost lost his presidency over it. When that disaster propelled the Republicans into control of Congress for the first time in 40 years, they tried to go too far in the other direction, with a proposal to cut Medicare-spending growth so they could raise money for tax cuts. That forced the 1995 government shutdown that put Clinton back on top of the game. Thus it would be understandable if neither party ever wanted to go near the issue again.
But in this season of contentment, the calculation in Washington is that managed care, and its shortcomings, may be the only issue compelling enough to get voters to look up from their barbecue grills. Just back from his trip to China, Clinton plans this week to step up his road campaign for the measure he calls a Patients' Bill of Rights, which would offer a wide new array of protections to the more than 150 million Americans in managed care. House Republican leaders, though late to the issue, are offering a proposal identical to Clinton's in many respects. What remains to be seen is whether politicians are serious about passing a law or would just as happily settle for a campaign slogan.
That there is a new opportunity for action is largely due to an irony that Hillary Clinton would surely appreciate: much of what people feared from her massive and intrusive health plan has actually come to pass without it. Americans gave the private sector a chance to come up with an answer, and it turned out to be not so different from the one government was accused of offering four years ago: a big, complicated bureaucracy. While most Americans with health insurance say they're satisfied with their coverage, 35% of those surveyed in a TIME/CNN poll complained about the growing hassle involved with their coverage, and a wide majority expressed support for such reform proposals as the right to choose one's own doctor (79%) and the right to appeal HMO decisions to a neutral third party (70%).
Most voters like what they have seen coming from Washington in recent years: legislation that lets people keep their health benefits when they change jobs; that spends $24 billion to provide medical care to uninsured children; that requires Medicare to cover preventive screening for breast cancer, colon cancer and osteoporosis. The fact that at least two-thirds of the states moved ahead on reining in managed care has only increased the call for action on the federal level, because more than 40% of the U.S. population is covered under health plans outside the reach of state regulation.
Though health care has once again found its way onto the political map, the landscape has changed profoundly since Clinton launched his health-care crusade in 1993. In that unsteady economy, the question at hand was containing out-of-control costs and covering the 36 million Americans who lacked health insurance. That number has grown in the past four years. But with fewer people worried about losing their jobs and the health benefits that go along with them, the uninsured and their tragic stories barely figure in the debate. Instead, politicians have taken up the cause of the Great Insured Majority against the employers, HMOs and insurance companies that would deny them proper care. "How can you let some person with the mentality of an accountant...make the decision?" Clinton has demanded.
Traditional battle lines have been erased as well. The doctors who fought Hillary's health plan so fiercely in 1994, then sided with Newt Gingrich on Medicare in 1995, are now allied not only with Clinton but also with their sworn enemies, the trial lawyers. Both groups want to give patients the ability to sue their health plans for improper treatment. And the neat ideological divide between pro-business Republicans and populist Democrats is breaking down as well: some of the most conservative Republicans, including South Carolina's Lindsey Graham and Steve Largent of Oklahoma, are on record favoring some of the most liberal legislation. These Republicans don't like corporate bureaucracies any more than they like government ones.
Clinton was the first to recognize how ripe a target managed care had become. In 1996 he seized on protecting mothers and their newborns against health plans that forced them out of the hospital only hours after delivery. Republicans, led by New York Senator Alfonse D'Amato, quickly trumped the campaign against "drive-through deliveries" with their own legislation against "drive-through mastectomies." And soon G.O.P. rank-and-filers such as Georgia Congressman Charlie Norwood, a dentist, and Iowa's Greg Ganske, a plastic surgeon, were out ahead of most Democrats in fomenting a broader assault on managed care.
It took a while for G.O.P. leaders to warm up to a campaign that not only violates the party's core aversion to Big Government fixes but also alienates the business interests that are the party's political and financial lifeblood. Senate majority leader Trent Lott and whip Don Nickles put out the word last October that their party was on the side of the insurers, and it was time to strike back. "The message we are getting from House and Senate leadership is that we are in a war, and need to start fighting like we're in a war," an insurance-industry lobbyist wrote in a memo to her boss. When Clinton released his recommendations for legislation weeks later, the leaders issued a statement warning, "We should not allow the President to do through the back door what failed through the front door."
Defiant talk in Washington, however, was little comfort to Republicans who saw how well the issue was playing on the campaign circuit. Democratic attacks caught them unawares in special elections in California and New Mexico. John Linder, who chairs the House Republican campaign committee, warned G.O.P. candidates that while strangling the tobacco bill wasn't hurting Republicans, giving aid and comfort to the managed-care companies would. So G.O.P. candidates have been taking cover where they can find it. In the House, Norwood counted 90 Republicans among the 232 sponsors of his reform legislation; in the Senate, no less a bulwark of the right than North Carolina's Lauch Faircloth climbed aboard a similar bill when his challenger began claiming the Senator was in the pocket of insurance companies (see box).
By the time House Republicans announced the broad outlines of their bill two weeks ago, the party's leaders were scrambling to catch up with their own members. However late, their still-to-be-written bill was the tactical success they needed as lawmakers returned to face their constituents over the July recess. It put the party on record with an alternative to Clinton's bill while silencing more liberal proposals within the party's membership. It also set the formidable Clinton message machine off balance for a news cycle or two. Clinton senior adviser Rahm Emanuel was hailing it as "a pleasant surprise" even as Vice President Al Gore was dismissing it as nothing more than "a bill of goods." And it got just enough criticism from the insurance industry, which called it "a mishmash of cobbled-together ideas that are guaranteed to raise consumers' costs, reduce choice and generate more federal bureaucracy," to sound credible with everyone else. Still to come is a Senate plan.
If what both parties really want is a deal, it is not difficult to find one in what is already on the table. Both Clinton and the Republicans would give patients new outside avenues for appeal when their health plans deny them care, more information to help them select doctors, and assurances that they won't be stuck with the bill when the chest pains that send them to the emergency room turn out to be indigestion. Women are guaranteed the right to see a gynecologist; doctors, the right to advise their patients when expensive new procedures are better than the ones allowed under their health plan.
But with less than two months of lawmaking left before Congress adjourns to run for re-election, there is also plenty to fight about. Democrats are firm that patients be allowed to sue their health plans, an idea that Republicans and their business constituents find heretical. The House Republican bill contains a few land mines of its own, such as medical savings accounts (a risky experiment, Democrats say, and a sop to G.O.P. campaign contributors) and limits on malpractice awards (which the Democrats and their trial-lawyer allies warn would prevent the injured from recovering what they are due). Says Republican Ganske of his leaders: "They have included a melange of controversial ideas to make sure the bill won't pass."
That suits many congressional Democrats just fine. "We're not going to pass a meaningless and toothless bill and say it's important," vows Senator Ted Kennedy. A bloody brawl over managed care may be the Democrats' best hope for winning back the House. Which may suit the White House for its own reasons. Clinton aides say that ever since the tobacco bill went down--after the President assented to Republican amendment after Republican amendment, only to see the G.O.P. kill the whole package in the end--Clinton has lost his appetite for dealmaking. Says a Clinton strategist: "It really slapped down the forces for bipartisanship in the White House."
Some democrats are predicting a victory that will be swift, clean and total--if not on the floors of Congress then at the ballot box in November. Unlike tobacco, they say, this debate will not get caught in arguments over taxes and how to spend them. But that ignores the fact that it has been largely one-sided thus far. What opponents of reform will have to do is convince voters that the legislation would give them rights they don't need at a cost they don't want to pay.
Managed-care executives concede privately that this is a difficult argument to make when Americans have at least 10 years of nerve-racking experiences with managed care. But that doesn't mean the industry doesn't have some important and powerful friends. Says an executive: "We want to create an environment where the inside game is hell." When Republican Ray LaHood signed onto one of the managed-care reform bills, two executives of Caterpillar, his district's largest employer, quickly flew to Washington to register their unhappiness with him. Small-business owners--the operators of hardware stores, real estate agencies and Laundromats who form the bedrock of G.O.P. support at home--are even more upset at the prospect of a bill that could raise their insurance costs. Six Republicans, including Norwood, have already removed their names from the Norwood bill. A health-care-industry official put it bluntly, "You gotta climb over [local business leaders'] dead bodies to get to us."
That is the message the industry is trying to sell through such sympathetic characters as real-life small businessman Bonifas. But Americans may also remember how a fictitious couple named Harry and Louise devastated the Clinton health-care plan in a similar political ad five years ago. As they sat at their kitchen table, Harry and Louise fretted that the choices being promised by the government were really no choice at all. "They choose," Harry said, to which Louise countered, "We lose." Voters might say that's precisely the problem with managed care.
--With reporting by John F. Dickerson/Washington
Two Competing Plans
Last November, Clinton asked Congress for a "Patients' Bill of Rights." The Democrats introduced legislation in March, and two weeks ago the Republicans responded with a bill of their own. A look at the two proposals:
Where They Agree
--Provide women direct access to their obstetrician and
--Guarantee emergency-room access without prior approval from an
--Safeguard personal information
--Allow doctors to discuss with patients the full range of
--Provide the right to appeal a managed-care decision by going
to an outsider
Where They Differ
The Democratic Plan
--Allows states to let patients sue health plans for improperly
--Gives patients access to specialists "without impediments"
--Assures patients will continue to be treated even if their
doctor is unexpectedly dropped from a health plan
--Mandates coverage of reconstructive breast surgery after a
The Republican Plan
--Caps the amount that doctors can be sued for medical
--Expands medical savings accounts, tax-deductible savings plans
that help people pay for medical coverage
--Creates association health plans that enable small businesses
to pool together for coverage
--Creates regional supermarkets, called HealthMarts, where
families can shop for insurance