Health Reform: Who Pays?

June 27, 1994

Senate moderates pushing health care reform that puts the emphasis on individuals, not employers, in purchasing insurance may be on to something. The fact is that in the end it will always be individuals -- not employers, not the government -- who have to pay the doctor (and the hospital and the pharmacist and the insurance peddler).

When you have an "employer mandate," as Bill and Hillary Clinton propose, the cost is ostensibly covered by the boss. But employees inevitably feel the impact in the form of smaller


What the debate on Capitol Hill is really all about is cost shifting -- of somehow finding a way to force healthy, reasonably well-off people to help pay the bills of the sick and the less fortunate.

The nation's poor already are covered by Medicaid, the elderly by Medicare. But the nation's jerry-built health care system too often fails to cover lower-income people who are self-employed or working for employers who do not provide insurance. And why? Because insurance companies tend to deny coverage to those with pre-existing conditions and refuse customers the right to carry their coverage from job to job. Because healthy citizens or the millions of employees used to having their medical insurance extracted tax-free from their paychecks don't really want a change. Because there is so much red tape involved in medical billing that billions of dollars go to administration rather than health care.

A year ago -- remember? -- health care reform was widely regarded as a cause whose time had come. But then came the details, and from them emanated so many devils that today the whole reform movement could collapse. Republicans who once were guarded or cautiously supportive of health reform now seem more emboldened to oppose the Clintons outright.

Perhaps this can be blamed on the secretive way in which Mrs. Clinton concocted a vastly complicated 1,300-page bill. Perhaps can be attributed to a small-business lobby that cranked out the "Harry and Louise" commercials without ever quite informing the public that employers providing health care were carrying the water of their deadbeat competitors.

Be that as it may, the focus now is on proposals before the Senate Finance Committee that would throw out "employer mandates" and substitute them with insurance reforms, subsidies for the "working poor" paid for through tobacco and payroll taxes and vague prospects for taking further action -- perhaps even "individual mandates" -- if more than 5 percent of the population remains uncovered at century's end.

As many holes can be picked in this approach as in the Clinton proposal or its variations. But if it is theoretically correct that the individual is the end source of health dollars, then bipartisan proposals in Senate Finance deserve a fair hearing. The alternative, as even the Clintons are starting to suspect, could be nothing at all.

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