Lights! Camera! Health Care! - health care reform forums

A front-row look at the hottest show in town.

Welcome to intermission here at C-SPIN's Health Care Reform Theatre. With the release of President Clinton's health care reform plan -- the product of thousands of hours of closed-door meetings and much behind-the-scenes maneuvering by interest groups, consumer representatives and faceless bureaucrats -- this fascinating political drama enters Act II. Some argue that the nation is in for a rerun, that interest groups and members of Congress will once again stymie the political process. But others point to a relatively new player on the stage: the American public, which according to numerous opinion polls wants reform and is willing to pay something for it.

To understand this new dynamic, it is helpful to see how the Clinton administration has worked to build public support for reform. With us to discuss these developments is Uwe Reinhardt, Princeton University economist and widely respected critic of political theater.

To refresh your memory, the last time we spoke with Mr. Reinhardt he took a rather dark view of this play-in-process, saying that "what the head of the AMA thinks in the shower in the morning is so much more important [to Washington politician] than the aspirations of 10 million Americans" (see "What's Blocking Health Care Reform?" Common Cause Magazine, January/February/March 1992).

Much has changed in the ensuing 18 months. While surely the head of the AMA still takes showers, the growing health-care anxieties of tens of millions of Americans seem to hold more water with Bill Clinton and Hillary Rodham Clinton, Health Care Reform Theatre's new director and co-director.

The prospects for significant reform are "tremendous; there will be stunning changes," the ever-watchful Reinhardt believes. And when it comes to the influence of theater prima donnas -- the American Medical Association and others in the powerful medical industry -- he talks now in terms of has-beens.

Switching metaphors, he says, "The interest groups have almost no bullets left in their guns."

Others are withholding judgement. While key players do seem resigned to the Clintons' approach, their happiness ultimately lies in the details. Doctors, hospitals, insurance companies, drug makers and consumer groups all still have their own scripts. What roles will they play in the next act of this complicated drama?

Smaller ones, Reinhardt says. Because of the way Clinton directed the first act, the process of reforming the health care system now is about more than "the way health policy will be made. It has to do with democracy." The first lady's health care road show, along with public hearings, gave "people a sense of involvement."

And although actual policy-making remains "an elitist process," Reinhardt adds, the Clintonian production has featured a different group of elites. While previous reform efforts were dominated, and eventually doomed, by "the interest groups and individuals who make income off the system," this phase has been engineered by the hundreds of experts and government bureaucrats on the President's Task Force on National Health Care Reform.

The Clinton team has worked to develop two parallel plots. In one arena it has listened to the interest groups, worked to convince them that reform is inevitable and tried to marshal their support. In another it has adopted a theatrical approach to policy-making, working to build grassroots support that it hopes will be broad-based and strong enough "to reach over the heads of the interest groups," in Reinhardt's view.

"Politically, it's the most skillful thing I've seen in 20 years," he adds.

To see this strategy in action and to get a feel for likely developments, let's go now to two recent performances of Health Care Reform Theatre: the Robert Wood Johnson Foundation's "Conversations on Health" forum, and the first public meeting of the President's Task Force on National Health Care Reform, held just three days apart this spring on the same stage at George Washington University in Washington. Both events were broadcast live to a national television audience. Co-director Hillary Rodham Clinton was unable to participate but was ably represented by understudies Tipper and Al Gore.

Narrator Steven Schoeder, president of the Robert Wood Johnson Foundation, began with a cautionary note: "Everyone wants something from health care reform," he said. "But it is impossible that everyone can get all they want from it without giving up something too. In fact, it is highly unlikely that people -- and organizations -- can even get most of what they want without compromise."

This "compromise for the common good" theme was a common refrain. Al Gore's prelude was peppered with such not-so-subtle cues as "the days of business as usual are over" and the task "will not be easy."

Thus the stage was set for conflict. The Clintonites pitted large segments of the "medical-industrial complex," to quote Ms. Gore, against the "demands of the American people." Health and Human Services Secretary Donna Shalala drew the lines quite sharply. "We're really talking about what it means to be an American," she said.

The drama clearly was designed to move participants, politicans and the public toward a partially predetermined outcome. Consumers, business and labor leaders, some health care providers and several chosen "storytellers" outlined the complex dimensions of the nation's health care crisis. By repeatedly emphasizing the current system's shortfalls, using carefully orchestrated plot lines to assign blame and continually claiming solidarity with the public, the drama foreshadowed the substantial changes being planned by the Clinton production team.

Responding to calls for more preventive care, universal insurance coverage and a drastic reduction of administrative waste, Secretary Shalala intoned, "We're talking about fundamentally redesigning the system. We have to be candid. It's broken down all over the place." Tipper Gore repeatedly reminded the players that "the mandate for health care reform has come from the American people." Even more pointedly, in response to a question from moderator Ken Bode about how to care "for people who don't have PACs and special interest groups," Ms. Gore said, "You create a system of universal access to health care. We might as well get smart and compassionate and bring people in," she said. "It's costing us anyway."

If that message was not clear enough, the Clintons' script further developed the reform theme by carefully casting as the drama's villains insurance companies, drug manufacturers, doctors who over-specialize and over-test, and other key segments of the medical industry.

Drug manufacturers, for example, were asked, "Why are prescription drugs so much more expensive in this country than in other countries?" and hospital administrators why "some hospitals charge $5 for an aspirin and $35 for a towel."

A harsh spotlight shone on insurance companies throughout both performances. At the forum, two audience members were invited to relate their problems with preexisting coverage limitations. "The way the system is designed now," responded Tipper Gore, "the insurance companies basically say that life is a preexisting condition."

Some "villains," however, didn't always stick to their lines. After an extended period of insurance-company bashing, for example, Mary Nell Lenhard, senior vice president of the Blue Cross/Blue Shield Association, said, "We couldn't agree more with the need for insurance reform."

This constant search for more virtuous roles also led to some intra-industry one-upmanship. Eric Gustafson, president of the Independent Insurance Agents of America, said his organization "opposes the use of preexisting conditions," adding that, "unlike some, ours is not a deathbed conversion."

In another telling device, the drama's script created larger roles for health care providers other than doctors. Virginia Trotter Betts, president of the American Nurses Association, argued that the best way to save health care dollars would be to move away from doctor-centered, hospital-based, acute care. "The first thing we have to do is stop thinking just doctor," Secretary Shalala agreed.

When the doctors' turn came, they presented a less-than-harmonized chorus. Dr. Raymond Scaletter, chair of the board of the AMA, played that historically obstructionist organization's revised role with understated panache. "We have not, do not and will not defend the status quo," he said. But he went on to say that the AMA would not, under any circumstances, accept government-imposed controls on physicians' fees.

And the performance of Dr. Jane Orient, executive director of the American Association of Physicians and Surgeons, made clear that many doctors will continue to oppose government-designed health care reform. Assuming the role of outsider, Orient blamed the government for rising health care costs, blasted the notion of requiring people to join health maintenance organizations and explained why physicians are better than politicians at designing a health care system. Unlike doctors, "government officials do not take an oath to do no harm," she said.

In response, Vice President Gore extended to the physicians' lobby both an olive branch and a warming. He assured them that the government shares their desire to reduce administrative paper-work and cautioned that "everyone who's been making money off the system in the past 10 years will need to sacrifice to make the [reformed] system work."

The performance of Richard Davidson, president of the American Hospital Association, left critic Uwe Reinhardt shaking his head in amazement. Davidson depicted the hospitals, which almost singlehandedly scuttled a proposed Carter administration cost-containment measure, as the newest champions of health care reform. "Hospitals believe in scrapping the current system," Davidson said.

But the true scene-stealer of both performances was a pointed exchange between Vice President Gore and Stephen Elmont, vice president of the National Restaurant Association. After Elmont declared that a government requirement that all employers provide health insurance for their employees "would literally sound the death knell for many restaurants," he added that many restaurant employees "don't want health insurance."

That remark, plus Elmont's assertion that "the concept of mandates is un-American -- the mandates of anything," prompted Gore to engage Elmont in a Socratic civics lesson. By getting Elmont to agree that government-required health and safety inspections of restaurants benefit both owners and customers, Gore tried to bring him -- and other individuals and interest groups -- around to the idea of government-mandated, employer-provided health insurance.

But Elmont's response indicated that he and others will continue to fight specific elements of the president's reform package. "If I give an inch, I am terribly, terribly concerned about the cost of that inch," Elmont said.

Appearing more than willing to paint Elmont and other small business owners as anti-reform obstructionists if that was their intention, Gore asked the panel. "Will you oppose any plan you don't agree with 100 percent, or could you support a plan with one or two elements that were not pleasing to you?" After one or two panel members indicated some flexibility, Gore responded as if to commit them to it. "So, there's a willingness to compromise," he said. "Very good."

But Elmont was one of only a few characters willing to flatly and publicly oppose the apparent direction of the Clintons' health care reform plan. The deft orchestration by the Clinton team has left most players unable to do much more than jockey for position in a reformed system, Reinhardt says. Not that they won't lobby hard. Doctors, drug manufacturers and insurance companies will oppose price controls; small-business owners will fight employer mandates; insurance companies will try to slow the move toward larger risk pools; and consumers will fight for their freedom of choice in doctors and against the rationing of medical services.

But Reinhardt believes the president has managed to build "a strong [proreform] constituency." If Clinton can hold onto and strengthen that grassroots support as Congress debates the fine points of reform and interest groups crank up their lobbying efforts, his team will be able to go to the interest groups and say. "You're not going to subvert [reform] one more time because we have the people on our side."

The accuracy of our critic's observations remains to be seen. But, if nothing else, the debating and politicking will continue to be fascinating political the-ater, Reinhardt says.

Stay tuned.

COPYRIGHT 1993 Common Cause Magazine
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