Who killed health reform?

Perhaps it's presumptuous to declare health-care reform dead before the body is even cold--when there is, in fact, still a chance, technically speaking, that some sort of meaningful legislation will emerge from the tangled mess of Congressional- committee jurisdictions that have been wrangling over the Clinton Administration's proposal and a host of alternatives. Conceivably, the sundry Senatorial satraps who figure prominently in the debate- -Dole and Moynihan, Chafee and Breaux, Mitchell and Packwood, among others--will resolve their differences with each other, with the House of Representatives, and with the White House, and will agree on a measure that meets at least a minimal standard of real reform.

But as these words are written early in July, there seems to be every reason to conclude that once again, after half a century of failed attempts to institute a rational and humane health-care system in the United States, we've missed the boat--for this year and, it seems depressingly likely, for years to come.

Some sort of bill may emerge from the Congressional committees, survive votes in both houses, and be rendered acceptable to each in conference. Some sort of bill may be signed by the President, who will undoubtedly put the best possible face on it. But it will fall so far short of what was supposed to be achieved this year that it may occur to many Americans, on sober reflection, that no bill at all would have been preferable, since the current fiasco may well foreclose the possibility of genuine reform for a long time.

That is so because the argument will be made--is, indeed, already being made--that whatever feeble measure may be enacted this year, it must be "given a chance to work" before any new effort is made to overhaul the system. That argument alone can be stretched into a decade of temporizing and delay.

Let's try to remember, if we can, what has been all but totally obscured in the recent health-care debate--the major shortcomings in the U.S. system that were supposed to be remedied this year:

[paragraph] Adequate health care is simply unavailable to more than thirty-five million Americans who have no access to insurance they can afford to buy.

[paragraph] Those enrolled in employer-financed insurance plans live in fear that their coverage will lapse if they change jobs or become unemployed.

[paragraph] Even those who are securely enrolled in health- insurance systems are at the mercy of insurance companies which may drop them, or increase their premiums to exorbitant levels, because of "pre-existing conditions" or current health problems.

[paragraph] The entire system is enormously expensive, claiming a substantially higher proportion of our gross domestic product than is the norm in any other industrial nation, and delivering care that is not--as is often claimed--"the best in the world." It is, actually, comparatively poor care as measured by such indicators as life expectancy and infant-mortality rates.

These are not isolated problems to be solved piecemeal, in stages, one at a time, as they would be under virtually every one of the health-care reform plans still under consideration. The problems are interconnected, and they require a radical departure from business as usual.

Why are health-care costs so high in the United States? Primarily because, unlike most other countries (except South Africa, which may soon cease to be an exception) we operate our health-care system as a vehicle for the enrichment of those who have a piece of the action. Our physicians enjoy such embarrassingly high earning levels that the American Medical Association recently decided to modify the way it calculates mean income. Our pharmaceutical manufacturers produce redundant and sometimes hazardous combination drugs and sell them in this country at many times the prices they charge abroad. Our hospitals compete with each other by buying enormously expensive, wasteful, and duplicative high-tech equipment.

But by far the largest--and most easily remedied--component of our excessively costly system is insurance, which accounts for as much as a third of our health-care expense. Insurance companies treat no illness and heal no wound--but they are regarded as absolutely indispensable and untouchable in any reform effort. It might be easier to abolish the role of the beloved family doctor in the United States than to do away with the health-insurance peddlers.

As it happens, we have at hand-right next door in Canada--a successful model of a health-care system that operates without private insurance, and that saves the considerable costs we squander on insurance companies. The Canadian "single-payer" plan is simple and direct. Every resident carries a card that guarantees needed medical care. The government pays the bills in accord with a schedule of fees that is understood by patients and health-care providers alike. There is a minimum of paperwork (in contrast to our cumbersome and wasteful system) and no governmental interference in the health-care process.

This is not "socialized medicine," which we would prefer, but it is a rational, fair, and reasonably economic way of providing medical services. It is a way that is clearly understood by many millions of Americans, and public-opinion polls have shown broad support for it in many parts of the country. Why has it received no serious attention at all in the Clinton White House and only token interest in Congress? The first reason, of course, is the furious opposition of the insurance industry, which has a perfectly understandable commitment to protecting so rich a source of profits, and which has clout enough to get its way. The second reason is that a single-payer health-care plan would have to be financed by taxes--and any increase in taxes is anathema to our political leaders, even though most Americans who now pay for health insurance, as well as those who have no coverage, would realize a net gain under the single-payer plan.

In its desperate attempt to evade the compelling logic of the single-payer system, the Clinton Administration devised a bureaucratic monstrosity--hundreds of pages worth of structures and rules and stratagems that defy comprehension and resist the most benevolent attempt at political support. It was a compromise of a compromise of a compromise, but from the beginning President Clinton made it clear that he stood ready to compromise still further. Inevitably, the interest groups went to work, whittling away at what little was there. The President's rhetoric--and that of Hillary Rodham Clinton--in support of health-care reform belied the reality of a tepid, quarter-hearted effort to bring about minimal change. That's why every public-opinion survey shows that there has been a steady decline over the months of support for the very idea of reforming the system.

Who killed health-care reform? The easy answer--and it contains more than a germ of truth--is that Clinton bears the blame for advancing an empty and untenable proposal, and that the Democrats who, after all, control both houses of Congress, must share the blame for not mustering support for even his mild and ineffectual scheme, let alone for anything better.

But in a larger sense, we all killed health-care reform by subscribing to the Reagan Doctrine (though it certainly didn't originate with him) that taxation is evil, that concern for the common good is subversive, that the hope for a decent and humane society is soft-headed. We don't give a damn, most of us, for the welfare (or even the health) of our fellow citizens--not if it means having to pay higher taxes.

The politicians sense that's how we feel, and act accordingly. If we want them to act differently, we'll have to start feeling differently--and letting them know.