That’s what’s happening now, as rumormongers in fright wigs sponsor TV ads and make the rounds of the op-ed pages. If they get enough voters to back away, health-care reform-if it passes at all-will reflect the interests of the medical-industrial complex, not Yours. Doctors and health and insurance execs. along with their political-action committees (PACs), invested $8.3 million in Congress during the first 10 months of 1993, up 22 percent from 1991, reports Citizen Action, a Washington consumer group. The drumbeat of disinformation has been pounding away on four major issues:
The shoulder-shruggers say that those without coverage are mainly young workers who could buy health insurance but don’t, or people between jobs who will come under another plan soon. Even if that truly described the problem (and it doesn’t), I don’t see why their lack of coverage is OK. The uninsured see doctors less often than the rest of us, are more apt to need hospitalization for illnesses that could have been treated at home, go to the hospital in worse shape and die there more often. The cost of their treatment comes partly from taxes and partly from higher charges to everyone else.
The uninsured are counted by the Census Bureau’s annual population survey, which numbered them last March at 37.4 million. That’s UP from 32.6 million in 1988, with most of the losses falling on small-business workers and the self-employed. But many more probably lacked coverage during at least part of the year, reports Lewin-VHI, a health-care research-and-consulting firm that develops data for government and business clients. The total uninsured at some point during 1993 probably reached more than 51 million-almost one in four Americans under 65. The rest are only a pink slip away.
Fewer than two out of 10 of the uninsured are young people 18 to 24. Most of the rest are working adults (plus their spouses and children) who have no employee plan. Only 28 percent are officially classified as poor. Nearly 60 percent earn low to middle incomes; for a family of four, that means $14,300 to $57,300, pretax. The cost of family coverage can easily run from $6,000 to $11,000 a year. So even at the high end, insurance isn’t an easy buy. Around 3 percent lack policies because of an illness insurers won’t cover. Only 7 percent go bare by choice.
More than half of the uninsured depend on small firms or are self-employed. The voluntary health plan proposed by Rep. Jim Cooper assumes that competition will cut health-insurance costs by so much that employers will choose to help workers buy policies. But according to a 1991 Harris poll, more than half of small-business owners aren’t likely to purchase coverage even if the price drops by 50 percent.
Without health reform, the answer is increasingly no. Cost-conscious health plans are rapidly smothering fee-for-service medicine, where insurers allow you any doctor you want. In 1988, 89 percent of the employees in company plans could choose fee-for-service, KPMG Peat Marwick reports (its survey covered medium-size firms and up). By 1992, that number had shrunk to 65 percent. Left to itself, the market will eventually limit you to staff doctors at a health-maintenance organization (HMO) or the network of doctors in a preferred-provider organization (PPO).
Ironically, the Clinton plan-which critics claim will wipe out doctor choice-might actually preserve it beyond its likely free-market life span, says John Holahan of the Urban Institute. Your choices, Clinton says, must include at least one fee-for-service plan, giving you access to almost any doctor with such a practice, and one HMO with a “point of service” option.
Point-of-service HMO plans are proliferating. Those who choose them will normally see the does at their HMO. But they can also visit an outside doctor. This privilege is expensive. Today, you might pay an extra 20 percent premium, plus an annual $300 deductible, plus 30 percent of each outside doctor’s remaining bill, with a cap of $3,000 on your spending. But for the well-to-do, the choice makes HMOs more appealing. if they doubt a diagnosis, they can get another opinion.
At present, most employers don’t offer both of these doctor-choice plans. And none of the Congress’s managed-care bills requires companies to have them. So although the president draws the fire, his bill should open more doors than it closes. What the does don’t like is that Clinton would restrict their fees, while most of the other bills let them charge whatever they want.
Clinton would group most people into purchasing co-ops (alliances). Once a year you’d get a booklet containing details on the plans in your region. Members could choose the one they liked. Every plan would cover the same things, so you’d pick based on competitive factors like quality, convenience and price.
The Health Insurance Association of America (HIAA) has been sponsoring TV ads suggesting that the better plans won’t be on your alliance’s list. But the only plans it could refuse are those costing 20 percent more than average (although there must be a fee-for-service plan, regardless of price). So these ads mislead. There would, however, be many fewer health insurers, which explains the HIAA’s concern.
It doesn’t work. If Congress created subsidized pools for the uninsured, thousands of small businesses would drop their own plans and toss their lower-income workers onto the public. Other mini-reforms have drawbacks, too. Say, for example, that Congress left the insurers untouched except to require them to take all comers regardless of health. The insurers could still avoid many high risks by not hiring agents in low-income areas.
Clinton’s plan can’t pass as written; there are serious questions of cost and reach. But tinkering just preserves the status quo, which is what the critics in fright wigs want.
