No health care utopia

February 22, 1994|By Robert Kuttner

Washington -- THE insurance industry, the New Republic magazine and kindred critics insist that the Clinton health reform would drastically curtail free choice of medical care. The Health Insurance Association of America (HIAA), in a misleading ad campaign featuring the imaginary "Harry and Louise," claims the Clinton bill will limit your ability to pick a doctor or a health plan.

The once liberal New Republic has given eight pages in two recent issues to Elizabeth McCaughey of the conservative Manhattan Institute. According to Ms. McCaughey, Clinton's plan would impose "unwritten rationing rules," "limit access to specialists and high-tech care," and "limit how much money is in the pot" to treat sick people. Most alarmingly, Ms. McCaughey says the bill prohibits your right to go outside your plan and pay a private doctor.

But these critics compare a world of managed health care under the Clinton plan with a presumed utopia of free choice that no longer exists. Thanks to private managed care, the vast majority of us no longer have free choice of doctors, treatments or health plans. Most insured Americans receive coverage via their employers, which increasingly limits the choice of plans, doctors and covered treatments.

Health Maintenance Organizations (HMOs) also drastically limit choice of doctor, hospital and form of treatment. Fewer than 5 percent of Americans have old-fashioned policies with free choice of any doctor and without "utilization reviews" requiring doctors to get approval from insurance company bureaucrats.

Moreover, if you or anyone in your family has ever been seriously ill, you are effectively locked in to your present plan. Should you desire to switch to another plan, it will probably be at a higher premium -- if at all -- with a waiting period before coverage becomes effective and often with restrictions on what is covered.

Even more insidiously, private managed care plays bait and switch. The glossy insurance company brochure detailing your allowed coverage specifies such and such medical conditions, vTC and so many days of hospital care.

But when you get sick, the insurance overlords will strictly limit the care you actually get. Hospital stays have gotten progressively shorter, and insurance plan managers already do all the things to cut costs that the HIAA accuses the Clintons of. These, after all, are the people who invented managed care.

Ms. McCaughey's articles recount horror stories from the annals of managed care. She cites the difficulty of getting appointments with specialists, refusals to authorize expensive tests, limits on elective surgery, and "cookbook medicine" requiring approvals by utilization reviewers who answer 800 numbers.

But these outrages describe the present system, not Mr. Clinton's!

The key differences between the present, essentially unregulated system of managed care and Mr. Clinton's "managed competition" are that the Clinton system would have more generous benefits than most current health plans, unlimited right to switch plans annually regardless of medical condition, disclosure of now-secret insurance company side deals limiting actual coverage, and new accountability for plans to public authorities.

In her second New Republic article Ms. McCaughey insists that the Clinton plan would prohibit you from going to a doctor outside your plan. This is simply a lie.

The Clinton bill does prohibit doctors from collecting twice for the same service -- once from the plan and once from the patient. But you can still arrange to pay a doctor in full privately, just as at present. Of course, in practice few of us could afford that option if we were seriously ill.

The Clintons have taken a good deal of scorn for writing a 1,342-page plan. But health reform is inherently complex, and the present system is byzantine. Legislative critics, such as Rep. Jim Cooper (D-Tenn.), have offered "simpler" alternatives by airily ducking such issues as just what an acceptable plan must cover.

The one grave mistake in the Clinton "managed competition" approach, however, is that it builds on the present system of privately managed care by allowing insurance companies to be the primary managers. Although Mr. Clinton's version of managed care would be an improvement over the present one, it would be far better to have a single-payer system, in which medical professionals rather than insurance case reviewers determine the difficult trade-offs involving care and cost.

Supposedly, a single-payer program is the unrealistically "liberal" alternative to the "moderate" Clinton approach and the more "conservative" Cooper plan. For a entire week in early February, the press was full of front-page stories reporting that key business groups had decided to oppose the Clinton bill.

But last week, in a story that most papers buried, the very conservative 60,000-member American College of Surgeons decided to endorse -- of all things -- the McDermott-Wellstone single-payer bill. Surgeons have not suddenly turned liberal; they just don't like private managed care any better than the rest of us.

Health reform will likely pass Congress this year. Happily, the debate is wide open, the public is just getting educated, and the details are still very much up for grabs.

Robert Kuttner writes a column on economic matters.

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