Friday, October 15, 1993

Will Clinton's Health Care Reform Plan Work?

Nearly three weeks have elapsed since President Clinton outlined his Administration's health care reform proposals in his Sept. 22 address before a joint session of Congress. During this time, a diverse collection of players has been jockeying for position - lawmakers, consumer groups, medical industry representatives, unions, small and large businesses, doctors - all of them with interests at stake in the debate. Affected parties who sense that their interests are threatened have been voicing a steady stream of reservations about various aspects of the Clinton plan.

Let us view this tableau of discontent and protest from the perspective of the policy analyst. It is clear that we are already seeing glimpses of what might happen to the Clinton plan if it reaches the stage of actually being carried out, its directives translated into action and results - in other words, the implementation phase of the policy process.

The policy process does not end when legislation is voted on and passed. In fact, building a consensus to ensure passage of laws is only half the struggle. The remaining half of the process is the policy implementation phase. It is here that the ultimate effects of any given legislation are shaped and determined. Legislators can not simply conjure policy into being - in order to implement the laws they make, agencies and bureaucracies must be created, staffers and administrators hired, information made available to the public, monies and resources dispersed, etc. Without proper implementation of policy, true in spirit to the legislative intent which created it, no policy can succeed in its ultimate goals - making a difference, changing lives and circumstances, altering the status quo.

As outlined by Bullock and Lamb, there are several variables that analysts and social scientists have agreed are crucial to the ultimate success or failure of a given policy's implementation. These variables include policy clarity, specificity of standards used to evaluate the policy, presence of an enforcement agency, enforcer commitment, attitudes of those who benefit from the policy, monitoring, commitment of the enforcement agency's superiors, administrative coordination, costs and benefits, and direct federal involvement. We will explore how each of these variables has implications for the ultimate fate of Clinton's reform proposals. Briefly, we will also look at how health care reform might be affected by some of the implementation "games" as conceived by Bardach, i.e., problems that can arise when actors connected with the implementation phase decide to throw wrenches into the works.

The need for policy clarity means that the actors responsible for implementing policy (i.e., agencies or bureaucracies) must have clearly defined policy goals to work with.

The central problem with any discussion of Clinton's proposed health care reforms is that even at this point, the Administration's plan is still up in the air. In order to better deal with the initial flurry of opposition to some of the plan's elements and vague funding mechanisms, hasty finetuning is now underway and consequently, the plan has still not been presented in final legislative form to Congress. In order to weather the long months of political struggle ahead, the President and Mrs. Clinton have both repeatedly served notice that "the only (inviolable) parts of the proposal are the overarching principles, which call for security, responsibility, simplicity, choice, savings, and quality." (NYT, 9/28/93, p A10) These terms may only be soundbites designed to ensure that whatever compromises are eventually made, none that deviate too far from the President's plan will be considered politically feasible. However, by signalling that everything is still on the table, the emphasis on these six principles conveys a sense of vagueness that does not bode well for policy clarity.

The fifty state governments will ultimately be responsible for implementing President Clinton's reforms. His plan saddles them with a "mind-boggling array of new duties" (NYT, 9/23/93, p A1), everything from establishing new regional health care alliances to buy insurance for their residents, to paying subsidies to help poor people and small businesses buy their insurance (using state and federal money), to collecting the huge amounts of data needed to measure and compare the quality of care within their borders. In many areas, Clinton's plan does not give states clear instructions on how to accomplish these goals, such as how to "make sure that 'all eligible individuals,' including homeless people, drug addicts, and residents of remote areas, enroll in a regional alliance." (NYT, 9/23/93, p A12)

Specificity of standards means there must be reliable standards by which to measure the effects of a newly implemented policy. One of the most important standards by which the success of health care reform will be measured is how good a job it does in slowing the increase of health care costs, which have been spiraling out of control. In this regard, at least, the plan has built in specificity of standards. Since Clinton's proposed regional health alliances will all offer consumers a standard set of health benefits packages, cost comparison among plans and alliances will be relatively easy.

A similar specificity of standards exists in the plan's main funding mechanisms. There are four of them: savings to be realized through decreased Medicaid and Medicare expenditures (1), estimated revenues from taxes on tobacco products (2) and taxes on companies who opt to continue insuring their own employees instead of joining regional health alliances (3), and estimated increased tax revenues from economic expansion made possible by lower health care costs to businesses (4). Any deviation from these funding estimates once the plan is operational (for example, if people buy less tobacco products because of the level of tax, therefore generating less actual tax revenues) would likely be detected immediately.

Unless voluntary compliance with a policy's directives can be guaranteed, there is a need for enforcement agencies to be set up, charged with enforcing compliance. This need is particularly great in complex policy situations like health care reform, a reform process that will touch millions of people, thousands of institutions, and require them all to change long-established ways of doing things. On this count, which usually involves the creating of new bureaucracies, there is little doubt that the Clinton plan will fail to deliver.

"In (some) ways Mr. Clinton would make the system even more complicated. He would create new agencies and a complex new apparatus to buy insurance. There would be regional health alliances, health plans, a powerful National Health Board, a new Federal advisory committee to assess the reasonableness of new drug prices and a new Government agency to decide the number of young doctors entering each medical specialty." (NYT, 9/24/93, p A10)

On paper at least, these enforcement agencies will be charged with the responsibility of overseeing compliance with reform. The crucial question, however, is just how will compliance be achieved? If cost savings are less than projected in certain areas of the plan, what happens? "The government could withdraw subsidies to small businesses and low-income households. Or it could take over the operation of health alliances that failed to meet targets for saving, thus acknowledging failure of the plan's fundamental structure. As with nuclear weapons, it is hard to imagine use of such penalties. Determined efforts to reach the saving targets are likely to provoke a backlash from providers and patients." (NYT, 9/22/93, p A21)

There are several dimensions to enforcer commitment, or the willingness of those who actually staff enforcement agencies to carry out the enforcement of policy. Policy must be a priority for either the enforcement agency as a whole or individual staffers. There is also the question of agency co-optation, or the "capture" of an agency by the very forces it is supposed to be regulating. This can come in the form of representatives of the regulated being chosen to lead or serve in regulatory agencies, or interest groups exercising undue influence over the agencies that regulate them through their allies in legislatures.

There is a very real danger of such co-optation befalling the regional health alliances or other new regulatory agencies created by the plan, simply due to the complexity of the health care delivery system itself and the technical knowledge that will be demanded of people overseeing and dealing with the consequences of reform. However, the Administration insists:

"Consumers will be safeguarded by the requirement that the alliances' boards include equal numbers of representatives of employers, consumers, the self-employed and other covered groups. They would not include people associated with health care providers, law firms involved with health care, pharmaceutical companies or suppliers of medical equipment or services." (NYT, 9/25/93, p 8)

Attitudes of intended policy beneficiaries are crucial; their support, opposition or disinterest translates into varying degrees of pressure on legislators to act on a given policy when results of implementation are reviewed, and often means the difference between policy life or death. The reactions of key intended beneficiaries of health care reform such as doctors, older Americans, business owners, underinsured Americans, etc., will be the determining factor in the plan's eventual success. Of course, if the plan works well, it stands to reason that public reaction to it will be favorable. Currently, however, although Clinton's plan has the support of a majority of the public (with 61% saying they were willing to pay higher taxes so that all Americans would have guaranteed health insurance, even before Clinton's Sept 22. televised health care address) (NYT, 9/22/93, p A1), reaction from some intended beneficiaries is decidedly mixed. Doctors, for example, are split in their opinions of the plan roughly along lines of those who are still privately employed (hesitant about reform) and those who already draw salaries working for clinics, hospitals, group practices and HMO's (welcome the proposed changes). (NYT, 9/24/93, p A11)

The remaining five variables crucial to policy implementation are monitoring of policy compliance, commitment of the enforcement agency's superiors, administrative coordination, policy costs and benefits, and direct federal involvement. These are all relatively less central to the implementation of health care policy than the first five, for various reasons. Monitoring of policy compliance will be subsumed in the duties of policy enforcement as carried out by the regional health alliances and new health regulatory agencies created by the plan.

Commitment of the enforcement agency's superiors means, in the case of health care reform, the extent to which the Clinton Administration has committed itself to the enterprise, which is to say totally. This commitment is borne out of a widespread sentiment in the country at large that the health care delivery system does need reforming. It is a public mood that could shift, of course, and turn against health care reform, if during the process of implementing the Clinton plan things go awry.

Administrative coordination is important as it relates to the extent that agencies in the government with overlapping jurisdictions are able to cooperate on policy implementation. It will be important in areas where HEW has to work with the proposed National Health Board, other new regulatory agencies, and the regional health alliance boards.

"Mr. Clinton's proposal would open a new chapter in the history of Federal-state relations, placing huge new obligations on the states to run a social welfare program that would dwarf Social Security in terms of money." (NYT, 9/23/93, p A12)

Interesting problems could arise in matters involving coordination between state governments and the regional health alliances, because the health alliances will themselves be handling more money than most state governments!

Policy costs and benefits generally refer to the consequences of compliance or non-compliance with a given policy. The Clinton plan imposes increased tax costs on businesses who opt out of the regional health alliances, costs on individuals who choose more generous packages of health benefits than the norm, and various other measures intended to induce businesses and consumers to comply with the plan's reforms.

Finally, direct federal involvement refers to the extent which the federal government itself will be actually implementing policy.

"The Federal Government will have to issue dozens of new regulations translating any new law into terms that can be applied to doctors, hospitals, clinics, and insurance companies. But every state will need to pass legislation filling in details of the Federal framework." (NYT, 9/23/93, p A12)

Actions by the new National Health Board and other new health regulatory agencies notwithstanding, the bulk of Clinton's reforms will be implemented at the state level, by state governments and the new regional health alliances.

A final look at some of the implementation "games" as conceived by Bardach, and how they relate to implementation of health care reform. These games describe problems that can arise when actors connected with the implementation phase of the policy process decide, for various reasons, to derail or hinder successful policy implementation. Three games are of particular interest to us: Easy Money, Up For Grabs, and Piling On. Easy Money describes what happens when private sector elements find they can take undue advantage of the government trough via involvement in some public program, and by ripping the program off manage to circumvent or subvert any goals policymakers may have had of getting a good job done cheap. There is already concern that some businesses may begin to play a variety of Easy Money called the "subsidy game" once Clinton's health reforms pass. Since the Clinton plan would subsidize the purchase of health insurance for businesses with less than fifty employees, the fear is that some medium-size businesses will re-organize into smaller firms, in order to take advantage of the subsidies.

Up For Grabs is a predicament similar to the situation that confronts a regulatory agency in danger of being co-opted by the interests it is supposedly regulating. It happens when a policy mandate is formulated that "may have been the result of strong pressures on government to do something about what is generally perceived to be an urgent social problem, even though no one quite knows what ought to or could be done." (Bardach, p 90) Sounds almost like health care reform, doesn't it. As previously stated, regardless of the Administration's assurances that consumers will be given equal or greater representation than medical insurance and pharmaceutical industry representatives on regional health alliance boards, the whole spectrum of new agencies and deliberative bodies responsible for overseeing reform will be very much Up For Grabs. The five giants of the medical insurance industry - Prudential, Cigna, Aetna, Travelers, and Metropolitan Life - as well as the more than 70 Blue Cross and Blue Shield plans and dozens of already established HMO's have already staked out enormous victories in terms of the plan's general outlines, which assign them all central, very profitable roles.

Finally, there is a game called Piling On. This describes what happens when onlookers see a new program gathering speed, and attempt to use it for the advancement of their own political objectives. The obvious way in which this game is now being played with respect to health care reform is on the issue of abortion. The federal government has blocked abortion subsidies to poor women since 1981, through a series of anti-abortion amendments sponsored by Rep. Henry Hyde, (R-IL). The most recent attempt to defeat the Hyde amendment by passing a national pro-choice bill went nowhere. Pro-choice advocates are now attempting an end run around their most recent legislative defeat by insisting that abortion be covered under the Clinton health care reform package, regardless of whether or not doing so would jettison the bill's chances of final passage. This development presages a trend which will undoubtedly intensify during implementation of reform. Interest groups will likely mobilize to have benefits added to the plan's standard coverage package which are not currently covered, i.e., dental and eye care for adults, hearing aids, in-vitro fertilization, etc. With the addition of every added benefit, the plan's costs will increase, growing heavier and heavier under its burdens and edging ever closer back to the state of spiraling health costs which occasioned reform in the first place.

In closing, I'm sure glad I'm not the one responsible for eventual implementation of Clinton's health care reforms. I hope they work, and they look somewhat more promising when analyzed in terms of variables important for successful implementation, but there are too many games that could be played, too many pitfalls - I guess the whole thing is still too much of a Rube Goldberg contraption for me.

Attitudes of (intended) program beneficiaries: a short case study

"'One of my main reasons for being a doctor was I wanted to run my own clinic', said David Williams, 24, who is from a suburb of Salt Lake City and is interested in rural medicine. 'I wanted to do it on my own, and it sounds like he's trying to force all doctors into larger health care organizations instead of allowing any kind of entrepreneurial spirit in doctors.'" (NYT, 9/24/93, p A11)

"The uneasiness elsewhere in the nation over the proposal dates to a bygone idea of health care, Dr. Crosson (a doctor employed by Kaiser Permanente, the nation's largest HMO) said. 'Most people have grown up with a clear vision of what medicine is about,' he said. 'It's one physician...practicing by themselves in a small office with a nurse.' But with technological advance, Dr. Crosson said, 'the black bag could not hold all the tools of the trade, the small office could not contain all the tests and interventions a patient could need.' Thus group practices became more common and 'the new challenge became how to deliver that complicated care in a way that's still personal.'" (NYT, 9/24/93, p A11)

"A giant national health care system, many (medical students) feared, would only aggravate a trend toward having to practice medicine by bureaucratic decree, whether from the government or a private insurer." (NYT, 9/24/93, p A11)

"Other (insurance company) employees were skeptical that a vast new Government bureaucracy could streamline anything, let alone medical care paperwork. They said the most up-to-date HMO's already had more ambitious goals, like getting rid of all paperwork." (NYT, 9/24/93, p A11)

"While poor people worry that their needs may be neglected, state officials, for their part, fear that the Clinton plan may duplicate a fundamental problem of Medicaid: the proliferation of Federal mandates without enough Federal money to pay for them." (NYT, 9/23/93, p A12)

Thursday, October 14, 1993

Incidents in the Life of a Slave Girl by Harriet Ann Jacobs

Over the nearly two and a half centuries that human chattel slavery existed in North America, its primary victims were the African slaves whose lives were shackled and destroyed. Transported to the New World in chains, held in bondage for generations - there can be no question that their sufferings were incalculably immense. Nor is it untrue that white slaveholders profited greatly from their labors and thus materially benefited from the slave system.

At the same time, however, in seeking to catalog the full range of sociological effects that slavery's existence spawned, we must not forget that the South's "peculiar institution" also poisoned the lives of its supposed masters. The culture of almost unspeakable brutality that slavery created trapped slaveholders and their families in webs of barbarism, indecency, and ignorance, just as surely as it trapped slaves in lifetimes of misery and hardship. Anyone who wants to understand the complex history of relations between black and white Southerners has to go back to the conditions of slavery, and see how both races were scarred by its oppression.

Harriet Ann Jacobs' autobiography, Incidents in the Life of a Slave Girl, was first published in 1861. She wrote it under the pen name Linda Brent. At that time, Jacobs was forty-three years old. She escaped from slavery at the age of twenty-seven, after spending nearly seven of those years hiding in a small garret above a shed in the South Carolina community where she was born (p 151), almost within sight of her master's home. This narrative conveys a wealth of information about the oppressive conditions endured by Jacobs, her family, and other slaves she knew. It also sheds fairly detailed light on how the mechanisms of slavery functioned to perpetuate its hegemonic reign by exploiting class and gender fault lines among whites who were themselves harmed by the existence of slavery.

Slavery could not have preservered for so long without the support of the mass of white southerners, i.e., those whites who were not part of the planter elites. Most poor whites in the South did not own slaves, and thus did not benefit in direct, material ways from the existence of slavery. If anything, the danger was that elements of the "low whites" would begin to recognize how slavery was contributing to their own economic domination. "The power which trampled on the colored people also kept themselves (poor whites) in poverty, ignorance, and moral degradation" (p 65).

Planters who owned slaves were able to amass enormous amounts of wealth, accumulated capital that was then put into service vis-a-vis land speculation, and control of banks, retail and manufacturing concerns. These were all advantages that poor whites lacked, could not help but resent, and which together formed a framework of economic oppression that directly harmed them. Something had to be done to prevent poor whites from looking too closely at the roots of their own lowly economic status and finding common cause with the enslaved blacks.

The ideological trappings of white supremacy served to keep these whites in line. Slavery's hegemony was propped up by the construction of an elaborate, racially ordered social system. Its message to poor whites was that no matter what their status was in relation to rich planters, they were still superior to the wretched mass of black slaves and always would be.

On occasions when the slave system felt threatened, such as during the aftermath of Nat Turner's rebellion, in late August, 1831, poor whites would be given opportunity to directly exercise this right of racial superiority. Poor whites were organized into companies and patrols (under the command of rich planters, naturally), and given license to freely plunder the homes and quarters of all colored people in the area, slave and free alike.

"It was a grand opportunity for the low whites, who had no negroes of their own to scourge. They exulted in such a chance to exercise a little brief authority, and show their subserviency to the slaveholders" (p 65).

How the poor whites responded to their own impoverishment was revealed by their reactions to the bedding and table cloths, silver spoons, and preserves discovered when Jacobs' grandmother's house was searched for arms and other evidence of insurrection.

"'Look here, mammy,' said a grim looking fellow without any coat, 'you seem to feel mighty gran' 'cause you got all them 'ere fixens. White folks oughter have 'em all." (p 66).

Their poverty bred resentment, which was channeled into jealousy of and hatred for the slaves and freedmen who lived in anything but utter squalor. Thus, the slave system's hegemonic rule was skillfully maintained through hidden ideological control. Racism and the doctrine of white supremacy were used as clubs to blind poor whites from seeing their own economic interests.

Elite white women in the South also suffered (in a qualified and very particular sense) from the perpetuation of injustice and exploitation that slavery engendered. The wives, sisters, and daughters of slaveholders were forced to exist in a society where the sexual exploitation of slaves made a mockery of marital vows. Pain and disharmony were sown among the families of "privileged" white Southerners whose lives were supposedly being enriched by slavery.

"The young wife soon learns that the husband in whose hands she has placed her happiness pays no regard to his marriage vows. Children of every shade of complexion play with her own fair babies, and too well she knows that they are born unto him of his own household. Jealously and hatred enter the household, and it is ravaged of its loveliness." (p 35).

Most slaveowners' wives probably responded as Mrs. Flint did when she learned of Dr. Flint's plan to have Linda (Harriet Jacobs) sleep in his room, ostensibly to keep watch over his youngest daughter (p 31-32). Being confronted by the realization that their husbands were having sexual relations with slave women in most cases did not translate into a lessening of support for slavery as an institution among slaveowners' wives. Here, the hegemonic system of white supremacy intertwined with the framework of patriarchal domination that ordered American society. Rage that might have been directed at the institution of slavery was thwarted, run through an ideological wringer of notions about romance and rivalry, and instead transformed into feelings of simple jealousy and hatred, directed against the slave women who had been raped by their husbands.

"She (Mrs. Flint) pitied herself as a martyr, but she was incapable of feeling for the condition of shame and misery in which her unfortunate, helpless slave was placed" (p 32). Their cruelties towards these women, who they saw only as "rivals," undoubtedly increased, and the slave system was strengthened, not weakened.

If the poor whites and elite white Southern women whose interests were not served by the slave system had ever revolted, the foundations of slavery might have collapsed long before the Civil War. It was thus essential that coherent ideological constructs be present to gloss over inconsistencies between slavery's professed benefits to all Southern whites and the day-to-day realities of its sexual and economic exploitation.

Paradoxically, the only elements of the slave system that could have turned wives against their slaveowning husbands and poor whites against their rich planter "masters" instead served to harden the hearts of Southern elite white women and poor men even further against their human sisters and brothers in bondage.

Source: Incidents in the Life of a Slave Girl (1861) by Harriet Ann Jacobs

Monday, October 4, 1993

Who Will Decide the Fate of Clinton's Health Care Reform?

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.

Rogues Gallery

All Posts by Category


#ChapelHillShooting #MuslimLivesMatter (1) $400 haircuts (3) 1960s (1) 1980s (1) 1984 (1) 1988 elections (1) 1989 (1) 1990 elections (3) 1992 elections (1) 1993 (3) 1994 elections (1) 1996 elections (3) 1998 elections (1) 2000 elections (3) 2004 (7) 2004 elections (2) 2008 (32) 2008 congressional races (2) 2012 elections (3) 2014 elections (13) 2016 elections (7) 527 groups (1) 9/11 (4) 9/11 first anniversary (1) Abba Eban (1) Abbe Raven (1) Abbie Hoffman (2) ABC (1) abortion (3) action alert (7) activism (2) advertising (2) advocacy (1) affair (4) Affordable Care Act (1) affordable housing fund (1) afghanistan (2) Age of Obama (1) AIDS (1) AIDS victims (2) AIPAC (1) al gore (2) Al Sharpton (1) Alec Guettal (3) alienation (2) Alison Lundergan Grimes (1) alternative energy (10) Alzheimer's (1) amanda marcotte (2) American Left (4) Americans for Limited Government (1) Americans For Prosperity (1) Amnon Rubenstein (1) andrew young (3) Angelo Robinson (1) anti-communism (1) anti-gay bigotry (1) anti-gay violence (1) anti-immigration activists (2) anti-science (1) anti-Semitism (1) anti-vaccine (1) anti-vaxxers (1) anti-war (6) appeal to southern voters (1) apprentice (1) Ariel Sharon (1) Ashley Todd (2) assassinations (2) Astroturf (1) atheism (1) attack ads (5) attack on voter rights (4) Australia (1) autism (1) average Americans (1) baby boomers (1) baby formula (1) bank of america (1) bankruptcy reform (1) barack obama (24) Barry Commoner (2) BBC (1) Benghazi (1) Benjamin L. Ginsberg (1) Bensonhurst (1) Berkeley (1) Beth Ising (2) bi-racial coalition (1) Biden-Palin Debate (1) big banks (1) big money (4) bigotry (7) bill clinton (6) bill donohue (1) Bill Hedrick (1) Bill O'Reilly (1) billionaires (1) Billy Bragg (1) Black Cultural Center (1) Black Lives Matter (4) black voters (7) Blan Holman (1) block the vote (1) bloggergate (1) bloggers (1) blogosphere (1) Bob Dole (1) Bob Iger (1) bob johnson (1) body cameras (1) books (3) Borders (2) BP (2) Brad Blog (1) Brad Friedman (1) Bruce Braley (4) budget deficit (1) bush (7) Bush Administration (2) bush administration misconduct (3) bush donor (1) bush on steroids (1) bush v. gore (1) California (1) Camilo Padreda (1) campaign feud (1) campaign finance reform (8) campaign gaffes (2) campaign scandals (4) campaigns (1) can edwards win (3) canvassing (1) capitalism (2) Catalyst (5) censorship (5) Cesar Chavez (1) Chad Taylor (1) Channel One (1) chapel hill (7) chapel hill town council (3) Charlie Black (1) Charlie Crist (1) Chatham County (1) chemical industry (2) children (1) chris hughes (1) Chris Whittle (1) Christine O'Donnell (1) CIA (3) CIA recruiting (1) CIA torture report (1) citizen participation (1) Citizens United (1) civil disobedience (2) civil rights (7) civil rights movement (1) civilian casualties (2) Civitas Institute (1) class issues (1) Clean Up Congress (1) Clear Channel (2) Clinton Administration (3) code words (1) Cold War (1) colin powell (1) Colin Small (1) college campuses (2) colonialism (1) columbia (1) community reinvestment (1) community reinvestment act (1) concentration of mass media ownership (4) Concord (1) congress (7) conservation (1) consumer fraud (2) consumers (2) Coors (1) corporate accountability (8) corporate front groups (1) corporate giveaways (2) corporate greed (1) corporate influence (4) corporate media (2) corporate misconduct (8) corporations (8) corruption (1) counter-inaugural (1) CRA (1) cra-nc (2) Craig Hicks (1) CRomnibus (2) crony capitalism (1) cross burnings (1) Crossroads GPS (1) Cuba (1) cuban exiles (1) cultural imperialism (1) Dale McKinley (1) damage control (2) Dana Rohrabacher (1) dark money (3) Darren Wilson (2) David Ball (2) David Brower (1) David Dellinger (1) David Duke (1) David Horowitz (1) Deah Barakat (1) debates (1) Debbie Cook (1) demagogues (3) democracy (6) Democratic Convention (1) democratic nomination (15) democratic party (2) Democrats (2) Denis Hayes (1) deregulation (1) detainees (1) Dick Cheney (1) dictatorships (1) dirty tricks (4) discrimination (1) Disney (1) disparate treatment (1) diversity (1) divisive politics (3) Dominican Republic (1) Donald Rumsfeld (1) donald trump (4) dumpstering (2) durham (2) e-mail (2) early voting (2) Ebola (2) economic inequality (2) economic issues (1) economy (4) ed meese (1) Ed Rollins (1) Edison Project (1) edith childs (1) education (2) edwards affair (4) election day 2008 (1) election fraud (1) electoral college (1) Eliot Spitzer (1) Elizabeth Dole (1) elizabeth edwards (2) Elizabeth Warren (3) Emily Lawson (1) employee pensions (1) end racism (4) energy independence (9) entertaining ourselves to death (5) environment (15) environmental pollution (5) environmental racism (2) Eric Garner (2) Eric Holder (1) Eric Odell (2) Ericka Kurz (21) evan bayh (1) Executive Orders (1) expenditures (1) exploitation of 9/11 (2) Exxon Valdez (1) factory farming (1) Faux News (1) FBI (1) Fear (1) fec (1) feminism (1) Ferguson (3) Fidel Castro (2) field plan (1) financial house of cards (1) fire (1) Fire From The Mountain (1) firebombing (2) fired up (1) first openly gay elected official in south (1) Florida (1) florida recount (1) foreign policy (1) Fox News (1) fraud (1) fraudulent inauguration (2) Frederick Douglass (1) Free Speech Movement (1) freedom songs (1) friend (1) fuel efficiency (1) fundraising (2) gary hart (1) gay (6) gay history (2) gay marriage (1) gay-baiting (4) Gaza (2) gen. david petraeus (1) gender equality (1) general election (23) Generation X (1) George H.W. Bush (9) George Norris (1) george w. bush (12) Geraldine Ferraro (1) Germany (2) gerrymandering (1) get-out-the-vote (3) GLBT community (1) global warming (2) GOP (27) GOP Slime Machine (10) GOTV (3) government harassment (1) government secrecy (1) great recession (1) greed (1) Greg Orman (1) grocery store (1) ground game (1) ground zero (1) GSE's (1) guerrillas (1) guest workers (1) Gulf War (5) gun violence (1) h+r block (1) hackers (2) Hamas (2) Harriet Ann Jacobs (2) Harris Wofford (1) Harry Blackmun (1) Harry Truman (1) Harvey Gantt (6) hate crimes (1) hate-mongering (3) hatred (3) health care reform (4) hedge funds (2) Helen Caldicott (2) Henry Hyde (1) Henry Kissinger (1) Henry Louis Gates Jr. (1) hero (1) Hezbollah (1) hillary clinton (14) historical amnesia (1) history (1) hit the road jack (1) HMO's (1) Ho Chi Minh (1) hoaxes (1) Holocaust (1) home foreclosures (1) homophobia (1) housing (1) Howard Rich (1) HR 1461 (1) Huks (1) Human Rights Campaign (1) hurting communities (1) i feel pretty (1) iit’s a wonderful life (1) immigration (4) immigration action (1) immigration reform (3) Inauguration Day 2009 (1) Incidents In The Life of a Slave Girl (2) income inequality (1) Indigo Girls (1) industrial agriculture (1) industrial revolution (1) integration (1) intelligence community (1) international relations (1) Invasion of Panama (1) Iowa (4) iowa caucuses (1) Ira Magaziner (1) Iran/Contra scandal (1) iraq (2) iraq war (4) iraq war costs (2) Irgun (1) ISIS (1) Islamic State (1) Islamophobia (1) Israel (5) Israeli Labor Party (1) Israeli-Palestinian conflict (6) James Bay II (1) James Carville (1) james watt (1) January 20 2001 (2) January 20 2009 (1) jeb bush (3) Jenn Karson (1) Jenny McCarthy (1) Jeremiah Wright (1) Jerry Falwell (1) Jerry Rubin (1) Jesse Helms (13) jesse jackson (3) Jessecrats (1) Jesus de Galindez (1) JFK Assassination (1) Jill Biden (1) Jim DeMint (1) Jim Hunt (3) Jimmy Langman (3) job losses (3) joe biden (3) joe herzenberg (3) Joe Sestak (1) joe trippi (1) John Boehner (3) john edwards (12) john kerry (4) John Lennon (1) John Locke (1) John McCain (16) John Moody (1) john poindexter (1) John Raese (1) John Reich (1) John Sinclair (1) Joni Ernst (5) June 24 1973 (1) justice (2) justice for all (1) Justice for Mike Brown (1) Kansas (2) Karl Marx (1) Karl Rove (5) Kay Hagan (4) Kayla Mueller (1) Ken Calvert (1) Kentucky (1) Kirti Shastri (1) KKK (1) Koch brothers (4) Korean War (1) Ku Klux Klan (2) labor unions (2) Lakota Woman (1) Lamar Alexander (1) Larry Kissell (1) Latin America (2) Latinos (2) Lawton Chiles (1) lazy journalism (1) Lebanon (1) lee c. wilson (1) legal system (1) Lehman Brothers (1) lesbian (1) liberation theology (1) Libya (1) Likud (3) Linda Brent (2) Lisa Abbott (3) lobbying (1) Louisiana (1) love child scandal (2) lynching (1) macaca moment (1) MAJIC (1) Mandy Carter (1) Marco Rubio (1) Mark Chilton (2) Mark Kleinschmidt (1) Mark Penn (1) marketing (2) Martin Frost (1) Martin Luther King Jr. (1) Mary Brave Bird (1) Mary Crow Dog (1) maternity leave (1) Matt Czajkowski (1) max cleland (1) mayor of franklin street (1) mbna (1) McCain missteps (2) McCain VP (7) McCarthyism (1) McDesperate (4) measles (1) media (2) media bias (3) media failed to inform (2) media hysteria (1) media monopolies (3) medical insurance industry (3) Medicare (1) melissa mcewan (1) memorial (1) Menachem Begin (2) mentor (1) merger (1) Michael Bell (1) Michael Brown (3) Michael Stipe (1) Michele Bachmann (1) Michelle Bachmann (1) michelle malkin (1) Michigan (1) middle east (1) Miguel Recarey (1) Mike Castle (1) Mike Easley (2) Mike Hummell (1) military-industrial complex (3) Millennials (1) Milton Wolf (1) minimum wage (1) mission not accomplished (1) Mitch McConnell (3) Mitt Romney (6) Mobil (2) molly ivins (1) money (1) Moral Majority (3) MOVE (4) multiculturalism (1) multinational corporations (2) Muslim Americans (1) mybo (1) NAACP (1) Nat Turner (1) Nathan Sproul (1) Native Americans (2) nc (4) NC Legislature (1) NC MOBE 96 (1) NC PDP (1) neo-nazis (1) Nestle (1) netroots (3) New Left (1) New Orleans (1) New World Order (1) New York City (3) Nicaragua (2) no justice no peace (1) No More Bushes (1) nobama democrats (1) non-profits (2) North Carolina (23) North Korea (1) nuclear industry (3) Obama Inauguration (1) Obamacare (1) Obsession DVD (1) OCAW (1) occupied territories (2) October 28 2007 (1) offshore drilling (1) Ohio (1) oil (10) oil industry (6) oliver north (1) Omar Cabezas (1) online organizing (1) oppression (2) oprah (1) organizing (12) Orlando Bosch (1) Osama Bin Laden (1) ots (2) outrage (1) overconsumption (1) Palestine (1) pandagon (1) pat buchanan (1) Pat Roberts (2) Pat Toomey (1) patriarchy (2) Paul Wellstone (1) payday lending (1) peace (4) peace is patriotic (1) Peggy Young (1) Pennsylvania (2) Penny Rich (1) Peter King (1) petition (2) pharmaceutical industry (1) Phillipines (1) phonebanking (1) phony billionaire (1) picketing (1) PIRGs (1) PLO (2) police accountability (4) police brutality (5) police oversight (4) political committees (1) political consultants (1) political heroes (1) polls (1) pottersville (1) President Obama (4) presidential campaign (30) privatization of education (2) pro-war propaganda (1) profits (1) progressive Democrats (3) progressives (1) property (1) protest (2) protests (6) Public Citizen (1) public health (2) public opinion (2) publishing industry (2) pulp (1) pulping (2) PUMA (1) race card (1) race relations (5) race riots (2) racism (22) racist terrorism (1) radicals (2) Rafael Trujillo (1) rally (1) ralph nader (3) RALs (1) Rand Paul (2) ray charles (1) reading list (3) reagan's racism (1) recall elections (1) recession of 1991-92 (2) recession of 2008 (1) redbaiting (1) redistricting (1) refugee camps (1) refund anticipation loans (1) reproductive rights (1) Republican National Convention (2) republican party (2) Republican Study Committee (1) returns (2) revolution (1) rich donors (2) Richard Fink (1) Rick Santorum (1) Rick Scott (1) rielle hunter (2) Right Wing (11) right wing Republicans (11) RIP (3) rip-off (1) Robert McCulloch (1) Robert Mercer (1) Robert Redford (2) Robin Hayes (1) ronald reagan (2) Ruby Sinreich (1) rudy giuliani (1) ruling class (1) rush limbaugh (3) Sabra and Shatilla Massacres (1) Sam Brownback (2) same-sex marriage (1) Sandinistas (1) Sarah Palin (14) SAU (1) savings and loans (1) Scamdal (1) schools (1) Scientology (1) Scott Brown (1) SDS (2) SEAC (20) selected not elected (1) Senate races (10) sept. 11 (4) sept. 11 2002 (2) sexism (2) Sharron Angle (1) Sheldon Adelson (1) Shimon Peres (1) single payer health system (2) Six-Day War (1) slaveholders (1) slavery (2) Smithfield Foods (1) social movements (1) social networking (1) solar panels (1) soul music (1) south carolina primary (4) Soviet Union (1) spat (1) Sprint (1) Stand With Peggy (1) state governments (1) Steve Scalise (1) Steve Schmidt (3) stolen election (5) stop bush (1) StopBrownback (1) strange incidents (2) street theatre (1) Student Action Union (1) student activism (19) student voting (3) students (11) subprime lending (1) super PACs (2) superdelegate petition (2) superdelegates (2) supreme court (5) susan baylies (1) swine flu panic (1) Syria (1) take action (16) tax code fairness (2) Tea Party (8) Ted Cruz (3) terrorism (2) Terry Sanford (1) The Revolt (1) The Zionist Dream Revisited (1) these guys (1) third world (3) Thom Tillis (3) Thomas Frank (1) Threshold (8) tim kaine (1) Time Warner (1) tobacco industry (1) Tom DeLay (1) Tongass National Forest (1) Tony Coelho (1) Tony Mazzocchi (1) torture (1) Troopergate (1) trump was born wealthy (1) U.S. power structure (2) UNC-Chapel Hill (5) undocumented immigrants (2) unemployment (1) United Kingdom (2) universal healthcare coverage (6) unprovoked war (1) UpStairs Lounge (1) uranium mining (1) US foreign policy (2) US support for Israel (2) vaccines work (1) Vandana Ramaswamy (1) VANISH (1) veepstakes (4) vice president (6) Vietnam War (7) VOE (1) volunteers (6) vote packing (1) voter education (2) voter ID (1) voter intimidation (2) voter mobilization (1) voter registration (12) voter suppression (9) voter turnout (8) voter-owned elections (1) voters (7) voters for obama (2) voting (1) voting problems (1) voting rights (1) vp (1) Waldenbooks (2) Wall Street (2) walter mondale (1) war (6) war in iraq (5) war on terror (4) war on women (1) war profits (1) War Resisters League (1) war toys (1) war weary (1) waste (2) waterboarding (1) wealth (2) white supremacy (3) Whittle Communications (1) Winona LaDuke (3) Wisconsin (2) women (1) Woodrow Wilson (1) Woodstock (1) workers (1) workplace discrimination (1) World War One (1) xenophobia (2) Yippie! (1) Yitzhak Rabin (1) you're fired (1) young voters (1) youth (1) youth empowerment (2) youtube (1) Yusef Hawkins (1) Zionism (2)

Even More Outrage via

Twitter Outrage News Feed