It is mid-September, 1993. In one week, President Clinton will outline his long-awaited plan to reform the U.S. health care system. The vehicle will be a major address before a joint session of Congress, a speech which many people will view as a crucial test of Clinton's presidency. But for several days now, key elements of the health care reform plan have already been the subject of heated public debate. Unauthorized copies of the nearly-completed proposal were made by congressional aides and leaked to major media when lawmakers were allowed a preliminary look at the plan's details.
For months, and in some cases for years, the key actors in this debate have been jockeying for position and mobilizing for action. Now, their movements are entering the glare of public scrutiny. Rhetorical arguments are being constructed on all sides by those who have the most to win and/or lose in the coming debate. In order to understand what is at stake for all of us in the fight over health care, as Americans and as policy analysts, we must understand two things: who these key players are, and where their primary interests lie.
To these ends, it is useful to first think about the health care debate in the broadest possible terms. Three key legislative forces will be involved - the Clinton Administration, rallying behind its 500-member Health Care Reform Task Force, the Republican opposition in Congress, by nature hostile to Democratic policies, and the Democrats in Congress, themselves split along conservative/liberal ideological lines.
These three forces are in the process of coalescing into three further, somewhat overlapping circles of political support. The first is made up of those who favor the Clinton Administration's plan and want to see it enacted largely intact. The leading spokespeople for their cause are the President and his First Lady, Bill and Hillary Rodham Clinton, and Ira Magaziner, the Health Care Reform Task Force's senior policy advisor.
The second circle is composed of those lawmakers who are hostile to the aims of Clinton's plan and would like to see alternative but more conservative "solutions" to the health care crisis implemented, solutions less disruptive to the current practices and profits of the medical and insurance industries. Here, think of Sen. Bob Dole, the Senate majority leader and ranking Republican opposition figure, Sen. John Chafee, author of a Senate Republican alternative health care reform bill, and Rep. Dick Armey of Texas, the third-ranking House Republican and a staunch critic of Clinton's plan.
The third such circle involves lawmakers who are wary of the Clinton reforms mostly because they do not go far enough towards laying groundwork for a Canadian-style, single-payer system of government health care involvement. These mostly Democratic lawmakers support what are considered to be more "progressive" or "liberal" alternatives to the Clinton reform package. Sen. Paul Wellstone of Minnesota and Rep. Henry Waxman, D-Calif., are perhaps the most visible Congressional actors in favor of this course. Legislation in support of a single-payer system currently has 80 Democratic co-authors in the House of Representatives.
Behind these three shifting coalitions of lawmakers are various specialized blocs of the American public. Each circle of political support derives its political strength from different coalitions of special interests, i.e., individual groups who would be most affected by any changes made in U.S. health care delivery.
Thus, the first circle includes mostly parties likely to benefit somehow from enactment of Clinton's reform package. There is the Administration itself, which can expect widespread public gratitude for any successful reforms that improve the nation's access to health care. It also includes moderate Congressional Democrats, and some liberal Republicans in Congress, all of whom find common ground in wanting to steer a course between more conservative, "status-quo" oriented or liberal, "disruptive" approaches to industry reform. Moderate-leaning consumer groups such as Families U.S.A. have voiced support for the plan, mostly for the same reasons as these moderate lawmakers.
Support for the President's plan has also come from significant numbers of large corporations. In recent years, many have become fed up with the rising costs of providing health care benefits to their employees and are now only too happy to let the Government step in. This support for reform measures from big business is crucial to the Clinton plan's chances for success. It is an element of support which was non-existent in the past few decades during other periods of debate over health care reform.
The forces arrayed against a Clinton Administration engineered overhaul of the nation's health care system are united by varying interests. The rhetoric adopted by most Republicans, and a view more honestly shared by conservative Democrats and liberal Republicans who may want to see modest health care reforms pass, is that they are concerned about the plan's effects on small business and on the rights of ordinary Americans to choose their own doctors.
On a political level, however, it must be remembered that the overriding objective of most congressional Republicans is to gain political advantage from the battles ahead. Thus, despite talk of bipartisanship, the preferred Republican outcome of this debate would be to defeat the president's plan outright, or force compromises which will doom the plan to eventual failure and with it, the Clinton presidency.
Insurance companies, pharmaceutical manufacturers, and overpaid medical specialists are concerned primarily with ensuring that reforms do not cut too heavily into their individual profit margins. The National Federation of Independent Business, the nation's largest organization of small businesses, has also taken an extremely active role in opposing Clinton's plan. Led by a former director of the national Republican Party's executive finance committee, Jack Faris, the Federation finds fault with the plan's provisions for most employers with over 50 employees to pay 80% of their workers' health care benefit costs.
However, within the industry most directly affected by any eventual health care reforms, the medical insurance industry, there are important divisions. Under the Clinton plan:
"...most of the nation's 500 or so health insurers are likely to be driven out of the field, and among the likely beneficiaries would be the five giants of industry - Prudential, Cigna, Aetna, Travelers, and Metropolitan Life - as well as the more than 70 Blue Cross and Blue Shield plans." (New York Times, 9/19/93, p 1)
So while most smaller health insurance companies are opposing the Clinton plan tooth and nail, coordinating their efforts through an industry-wide organization called the Health Insurance Association of America, the industry's largest players are quietly supporting the plan's general outlines. For these giants, the Clinton reform prescription would be a goldmine.
Finally, there are those in Congress and the country at large who favor moving towards a Canadian-style, single-payer system of health care payment. Under such a system, the government would assume the role now played by private insurers in reimbursing doctors and hospitals for patient care. The Clinton Administration has stated its strenuous opposition to this option because of the turmoil it would bring in eliminating virtually the entire U.S. health insurance industry, including the industry giants which are protected and given near-monopoly powers under its own plan. In addition to advocacy by progressive Democrats in Congress, a single payer system derives public support from most major unions and most elements of the U.S. progressive movement. Polls have shown that the more the general public is told about how the Canadian system functions, the more people tend to favor U.S. adoption of a similar plan.
Also included in this circle are additional Democratic critics of the Clinton plan, who are less in favor of a single-payer system than they are critical of the Administration's assertions that cost savings will result in Medicare and Medicaid savings of two to three hundred billion dollars over five years. These Democrats, like Sen. Daniel Patrick Monyihan of New York, should be distinguished from more moderate or conservative Democrats in that they are more disposed to support the President's plan over Republican alternatives.
This brief description of the three circles of political support currently squaring off over health care reform is by no means exhaustive. Many other players are involved, and rightly so, since this debate directly involves players in 1/7 of our nation's economy, and whose policies and actions directly affect all the rest of us. Some important actors have yet to declare their allegiance to one of the three circles, such as the American Medical Association, the nation's largest association of doctors, and the American Association of Retired Persons, or A.A.R.P., the nation's largest senior citizens' organization.
Complex interplay between all actors and an ever evolving clash of alliances and strategies will characterize the debate as it continues to unfold, certainly one of the most important legislative and public policy struggles of the twentieth century.