Let's make a deal

May 24, 1994|By William Safire

WHAT'S the difference between the Clinton health plan and Elvis Presley? According to Sen. Phil Gramm: Elvis is the one that might be alive.

Nobody in Washington doubts that the president's grandiose scheme to place one-seventh of America's economy under government domination is dead. That's because Americans have come to realize that permanent price controls (euphemized as "premium caps") require rationing, or denial -- and most of us do not want the health care we already have taken away.

Equally obnoxious is the notion of statewide collectives (euphemized as "alliances") that would end the patient's freedom to choose a particular doctor. And forcing employers (the euphemism is "mandate") to bear the cost of insurance will hurt small business and cause workers to get fired or be treated as part-timers.

To top off the rising resistance, the proposal to finance coverage of the unemployed with a cigarette tax -- while we move to ban smoking -- is widely seen as the selling of unsaturated snake oil. The real bill, with taxes on the middle class, would hit home hard soon.

Does all that sober second thinking mean that "health care reform" is a dead duck? No. It means only that we have come to the time for improving health care's free market without undermining it.

First, forget "mandates"; forced coverage won't fly. That includes the misbegotten Republican alternative of "individual mandates," forcing each of us to buy our own insurance. Envision a TV spot this fall: "We Democrats want your employer to pay for your insurance, but the Republicans want to make you pay for it. Which do you prefer?" Sure answer: Force my boss, not me.

That's why Republicans will have to stop fiddling with compromises on coercion: Insurance must be voluntary. Plain economic sense, not legislation, will drive small businesses to form purchasing pools to get better deals from insurers.

Concentrate instead on an idea whose time has come: Everybody should be able to buy some health insurance. Clinton is right: "Pre-existing conditions" should no longer be a bar to getting coverage. The insurance industry will have to be forced to accept people who are poor risks.

These "community ratings," or risk-spreading among large pools of people, should not go to the extreme of human homogenization. Smokers and drinkers and gluttons should pay more than non-smokers and teetotalers and dieters; it's a free country, but if you choose to run a risk, you have no right to demand your neighbor share the cost of your risk.

The health insurance reform bill should include the ability to keep the insurance you have when you change jobs, provided you or your next employer pays for it. Portability of insurance fits in the new social and business fabric of our time.

To encourage more insuring, our tax system should give individuals, including the self-employed, the same tax breaks on insurance premium payments now given other employees. Medical IRAs are another way to help people pay for better coverage.

But won't this result in some people getting better health coverage than others? Yes. You work for money so that you can buy better food, better clothes, better housing and better health care than the next guy. Our system calls it "incentive."

That does not mean we let the poor starve, or lack for clothes or shelter, or deny them basic treatment for illness. But after providing a floor for those in poverty -- subsidizing premiums for the lowest-cost plans -- the better-off should not be prevented from providing better for themselves and their families.

The coming bipartisan health care bill ought to provide more JTC money for university medical research than does the abandoned Clinton plan, and should reject his odious imposition of racial quotas for medical schools.

It should encourage rather than disparage pharmaceutical research. It should stay miles away from a "National Health Board" -- which would come under political pressure to grant ever-greater benefits, at taxpayer cost, that individual Americans should remain able to choose or reject.

If Bill Clinton is re-elected with a larger majority in Congress, liberals could extend these sensible insurance reforms into the revolutionary health-care leveling they have in mind. If not, not.

William Safire is a columnist for the New York Times.

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