1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

Volume 49, No. 5 May 1993


On March 10, 1993, federal District Court Judge Royce Lamberth ordered the Health Care Task Force chaired by Hillary Rodham Clinton to comply with the Federal Advisory Committee Act. An injunction had been sought by AAPS, the American Council for Health Care Reform, and the National Legal & Policy Center (see AAPS News April, 1993).

``While the court takes no pleasure in determining that one of the first actions taken by a new President is in direct violation of a statute enacted by Congress, the court's duty is to apply the laws to all individuals,'' wrote Judge Lamberth.

The AAPS motion was granted in part, but denied in part. The Judge ruled that the interdepartmental working group and its cluster groups could meet in secret, based on his interpretation of the Separation of Powers doctrine.

Pursuant to the order, the Task Force belatedly filed a charter on March 17. The charter provides that ``the Task Force shall not delegate its responsibilities to subcommittees or subgroups'' and that ``the estimated cost of the Task Force is expected to be below $100,000.'' [The Task Force occupies two floors of the Old Executive Office Building.]

The first meeting of the Task Force, on March 29, was announced in the Federal Register March 17, stating that 15-day notice was not given (though required by law) because of the ``short time-frame within which the Task Force has been asked to report.'' On March 24, AAPS received a telefaxed invitation to testify as part of a panel of six physicians representing various medical organizations including the AMA (see testimony on p. 2).

At the 13-hour public hearing, witnesses were each allowed to make a three-minute statement. Each panel (representing interests such as ``underserved'' or ``hospitals'') was also questioned by the Task Force committee, chaired by Vice President Gore in Ms. Rodham Clinton's absence. The opening of a Public Reading Room was announced.

AAPS representatives gained access to Room 101G in the Dept. of HHS after three attempts to telephone the official in charge and a 15-minute wait in the foyer. After an NBC technician finished videotaping the materials, we were able to examine them: one 3-inch looseleaf binder containing the biographies of the witnesses at the public hearing and some of the materials they had FAXed in advance.

The following week, some correspondence from members of the public to the Task Force was available in the reading room. However, ``background and options papers prepared by working group members and seen by Task Force members'' were specifically withheld, according to the White House response to our Freedom of Information Act request.

Because the order exempted meetings of the working group from the requirement to allow public access, the government declared victory, stating that the injunction would have ``no practical effect'' on Task Force operations. Nevertheless, the Department of Justice filed an appeal, asking that the District Court's order be vacated.

About nine of 45 pages of the government's brief were devoted to an exposition of the definition of ``employee'' and ``officer,'' in arguing that the First Lady should be treated as such for purposes of exempting the Task Force from FACA.

The government questioned the distinction between informa- tion-gathering (which is subject to public scrutiny, according to Judge Lamberth) and the process of formulating policy recom- mendations (which may be kept confidential):

Decisions as to what information is pertinent, or what questions should be asked, are necessarily intertwined with the advisors' tentative policy views. The conduct of business would be hindered if advisors felt constrained to frame questions in a manner that did not reveal their own policy preferences.

The legislative history of FACA makes it clear that Congress also recognized the relationship between fact-finding and policymaking but intended both processes to be open. In 1972, Sen. Metcalf, a sponsor of FACA, stated:

Decision-makers who get information from special interest groups who are not subject to rebuttal because opposing interests do not know about meetings-and could not get in the door if they did-may not make tempered judgments.

For this reason, some congressional leaders differed strongly with Judge Lamberth about exempting Task Force subgroups from FACA. In a statement issued March 11, Sen. Charles Grassley (R-IA) said ``it is simply fiction to suggest that the cluster groups are somehow separate from the Task Force itself.'' He asked: ``Who are these people? What interests do they represent? What interests are gaining access to the making of very important public policy unbeknownst to the public?''

The answers to such questions should be in documents prepared by the working group for the Task Force. The right of the public to access these documents will be assessed in a conference with Judge Lamberth scheduled on April 13.

AAPS has filed a cross appeal (see p. 3), and the court has received amicus briefs in support of AAPS from the Pacific Legal Foundation and the National Taxpayers Union; J. Gregory Sidack; and six organizations representing the press (Reporters Committee for Freedom of the Press, Radio-Television News Directors Association, Newsletter Publishers Association, American Society of Newspaper Editors, Society of Professional Journalists, and the Associated Press).

Task Force Testimony

Statement of Jane M. Orient, M.D., on behalf of the Associa- tion of American Physicians and Surgeons before the White House Task Force on Health Care Reform, George Washington University, Washington, D.C., March 29, 1993

I am Jane Orient, Executive Director of the Association of American Physicians and Surgeons and one of 50 Past Presidents. I am in the solo practice of private medicine in Tucson, AZ. I speak as a physician who is bound by the Oath of Hippocrates.

By my Oath, I must refrain from doing harm to my patients, and I must abstain from mischief and corruption. I may not promise my patient a three-minute remedy and then give her a deadly potion.

Furthermore, I must ``follow that method of treatment which according to my ability and judgment I consider for the benefit of my patients.'' I may not subordinate my judgment to that of a secret council. I may not sacrifice my patient's welfare to a social agenda. I may not deny my patient a cancer treatment or heart surgery so that his resources can be used to benefit someone with a higher social priority, such as a person who is entitled to a free checkup.

I want the best medical care for my patients and for all Americans. We cannot provide the best until we get the cost down.

We will not lower costs by abolishing the Oath of Hip- pocrates and destroying the patient-physician relationship. The Oath of Hippocrates dates to the fifth century before Christ; the acceleration of American medical costs dates to 1965.

Costs skyrocketed because the government got into medicine. Costs will not decrease until we get the government out of medicine-

out of private physicians offices, where regulations are driving physicians out of business, especially in rural areas and inner cities;

out of hospitals, where compliance costs add a huge administrative overhead;

out of the pharmaceutical industry, where government adds $250 million to the cost of marketing a single new drug;

out of the medical marketplace, where government intervention has destroyed the normal economic mechanisms that keep costs reasonable in a free market.

We need to bring patients back into the financial equation. We must allow patients to benefit from their prudent spending and saving decisions. All Americans should be permitted to use pre- tax dollars to establish a medical savings account.

To preserve excellence in American medicine, we must preserve patients' freedom of choice-not turn it into the sham of picking Monolith A or Monolith B, both offering the same government-dictated benefits package.

If the government forces us all into a bureaucratically managed system, we will still have something called ``health care,'' delivered by persons called ``health care providers.'' But such a system will have no place for ethical physicians, whose Oath forbids them to accept a situation of conflict of interest with their patients.

Government bureaucracy has never controlled costs. The promise of universal access to comprehensive service under a global budget and government rules is, in a word, bankrupt.

Government officials do not take an oath to do no harm. What a government system can accomplish is to destroy the art and science of medicine in these United States of America.


Is Medical Care Different?

Someone once defined politics as ``the art of trying to prevent the inevitable'' ....

[M]edical care has been treated in total disregard of the principles of economics that are generally accepted in other areas of our economic lives....[B]ut it differs from other necessary goods such as food and heating oil in only two important respects.

First, no one ever suddenly needs 20 times more food or heating oil in one year....(That is why real medical in- surance...is needed.)

Second, even ordinary medical expenses come in fits and starts. This makes these ordinary but erratic costs more difficult to budget....However, the budgeting can be done....

Like any insurance, true medical insurance should cover only extraordinary costs. Most people should not collect on their medical insurance. (They don't really want to collect on their life or fire insurance....)

The deductible would probably be set so that only about 15 to 20% of families will exceed the deductible during a certain time period. Then prices would be determined mainly by the 80 to 85% of people paying directly for medical expenses-just as the price of two-by-four lumber is determined primarily by the demand of home builders rather than by the effects of insurance payments reimbursing for home fires....

The period of time covered by the deductible needs to be greater than one year; five years might be good. Then the cost of the usual hospitalization would not automatically exceed the deductible. (Currently, almost all hospitalizations do, so patients don't pay attention to costs.)

A budget and loan provision added to such a true insurance plan could take care of cases in which a family incurs a moderately high cost during the first few months. The difference between such an arrangement and current insurance payments is that any cost savings would be to the benefit of the patient, not the insurance company....

What about medical care for the really poor?

Why not ask, ``What about food for the really needy? What about heating oil?''

Private charity helps protect people from starving or freezing and can and does provide medical care. Government programs also operate in these areas-yet in the case of necessities like food, prices are determined mainly by the market forces generated by the majority of paying customers and producers. Medical care for the poor can be modeled along similar lines....

In short, we must allow patients to decide the quantity, quality, sophistication, and luxuriousness of the medical care they really want to receive. When polled in a survey, they will ask for the moon, but their real wishes will be known as they vote with their own dollars....(And think of the added incentives to change to a healthier lifestyle!)....

Sherwood Kaip, M.D., El Paso, TX

[Edited excerpts printed with permission. For a photocopy of the unedited article, please send a self-addressed, stamped envelope ($.52 postage).]

AAPS Cross-Appeals in Case Against the Task Force

On April 5, 1993, AAPS filed a cross-appeal in the US Court of Appeals for the District of Columbia Circuit in the case of Association of American Physicians and Surgeons, et al. v. Hillary Rodham Clinton, et al., responding to the Department of Justice's appeal filed March 22, 1993 (see p. 1).

AAPS argues that Judge Lamberth erred in dismissing the claim that the interdepartmental working group should also be subject to FACA, without allowing expedited discovery of the facts about its operation. The court simply accepted a declaration by Ira Magaziner, which is riddled with inconsistencies, without benefit of cross-examination.

According to recent press accounts, the group led by Ira Magaziner has held more than 400 meetings with selected interest groups. The Washington Post reported that the President has already been briefed for 12 hours regarding reform policies, although the Task Force has just held its first public meeting! The evidence suggests that the Health Care Task Force is a ``rubber stamp,'' a political facade for the real meetings with private interests.

In Nat. Anti-Hunger Coalition, appellants argued that the District Court's conclusions were called into question by

new evidence suggesting both that task force reports are transmitted directly to federal decisionmakers before they are made publicly available and that the subcommittee of the Executive Committee is merely ``rubber stamping'' the task force's recommendations ....Either of these facts, if true, might well have led the District Court to conclude that the task forces themselves were subject to the requirements of FACA.

AAPS reiterates its contention that Hillary Rodham Clinton is not and cannot be a federal employee. But if she is held to be such, she then falls under the provisions of the Hatch Act and is barred from participating in political campaigns. Furthermore, if she claims an exemption from the Anti-Nepotism Act based on the fact that she receives no compensation, this establishes a violation of the Anti-Deficiency Act (U.S.C.1342), which prohibits an officer or employee of the US government from accepting voluntary services unless there is an emergency involving the safety of human life or the protection of property.

In any event, Ms. Rodham Clinton is not the only non-federal employee on the Task Force, as the recently disclosed list of working group participants attests.

The government's argument that FACA is an unreasonable encroachment by Congress upon the powers of the Executive Branch, hindering its ability to meet a self-imposed deadline, simply strains credulity-especially since more than 150 congressional staffers have been invited to participate in the Task Force. In fact, it is the operation of the Task Force itself that violates the Separation of Powers.

In his amicus brief, J. Gregory Sidack explains that Separation of Powers can be violated if the executive and the legislature agree to ``exchange or commingle their duties or prerogatives so as mutually to diminish their accountability to the electorate.'' Hamilton's warnings in The Federalist, Sidack points out, could have appeared as easily in a 1993 newspaper report on the Health Care Task Force:

It often becomes impossible, amidst mutual accusations, to determine on whom the blame or the punishment of a pernicious measure...ought really to fall. It is shifted from one to another with so much dexterity...that the public opinion is left in suspense about the real author....

AAPS concludes that the reason for the government's broad and vague constitutional attack on FACA is patent: any claimed need for secrecy is fictitious, illusory, and purely politically motivated.

Oral arguments will be heard in the Circuit Court on April 30, 1993.


Foundations Targeted

Alain Enthoven outlined the principles of what he called the ``Guild Free Choice,'' ``non-competitive'' system that dominated American medicine into the 1980s, in a talk presented at a January workshop sponsored by the Robert Wood Johnson Foundation. The principles, targeted for correction under ``managed competition,'' and their economic consequences according to Enthoven, are:

  • Free choice of doctor by the patient. (This means that ``the insurer has no bargaining power with the doctor.'')

  • Free choice of prescription by the doctor. (This ``prevents the insurer from applying quality assurance or review of appropriateness.'')

  • Direct negotiation between doctor and patient regarding fees, without outside interference. (This ``excludes the third-party payor who would be likely to have information, bargaining power, and an incentive to negotiate to hold down fees.'')

  • Fee for service payment. (This ``allows physicians maximum control over their incomes by increasing services provided.'')

  • Solo practice. (In contrast, ``multispecialty group practice constitutes a break in the seamless web of mutual coercion through control of referrals that the medical profession used to enforce the guild system.'' In other words, it is the solo practitioner, not the group, who makes a ``seamless web,'' in Enthoven's view.)

Enthoven observes that commercial insurers ``remain financial intermediaries with expertise in underwriting risks, not in organizing, managing or purchasing medical care.''

Enthoven's address makes it clear: The purpose of ``managed competition'' is to turn insurers into ``health-care delivery systems'' and physicians into the undertakers of risk.

``Health-care delivery systems'' are designed for the benefit of the healthy, who are served by ``health-care providers''-not for the benefit of patients (the sick and the injured), who are attended by physicians.

Hillary Rodham Clinton explained the situation in a recent speech: ``What we currently have is a system for taking care of sickness. We do not have a system for enhancing and promoting health.'' The Chairperson of the Task Force for ``Health Care'' Reform has a vision for fixing that system.

President Clinton likes to use the word ``contribute'' instead of ``sacrifice'' for more taxes....Sort of like in the old days when virgins were ``contributed'' to volcanoes.Toback & Co.

New Members

AAPS welcomes Upper Cumberland Orthopedic Surgery of Cookeville, TN; Northwest Eye Surgery of Columbus, OH; and Drs. Stanley L. Alexander of Centerville, OH; W. Carl Allen of Seattle, WA; Haley Barbour of Washington, D.C.; Susan Barkell of Farmington, NM; Lydia Bartholomew of Renton, WA; Brent Bauer of Scottsdale, AZ; James Beattie of Bowling Green, KY; Roland Beaudry of Port Arthur, TX; Paul W. Becker of Spokane, WA; Gregory Bergman of Minster, OH; Stanley D. Berliner of Lake Success, NY; Bruce H. Bern of San Mateo, CA; R. W. Blanco of Tampa, FL; Daryl K. Boffard of Union, NJ; Glenn Bonacum of Spokane, WA; Marc R. Brown of Dallas, TX; Frank L. Buomo of Bowling Green, KY; Curtis Burnett of Seattle, WA; Susan H. Carlyle of Houston, TX; D. T. Cassidy of Reno, NV; Barry H. Cohen of Plandome, NY; E. Scott Conner of Santa Barbara, CA; Marshall L. Cook of Tucson, AZ; Robert L. Cooper of Mt. Pleasant, TX; Robert E. Cox of Edmonds, WA; Charles H. Cozean, Jr. of Cape Girardeau, MO; John D. Credico of Lawrenceburg, TN; Peter A. Curka of Houston, TX; Donald P. Dallas of New York, NY; Venancio DeCastro of Arlington Heights, IL; Michael DeHaan of Seattle, WA; Robert S. Emmons of Burlington, VT; A. Erickson of Grass Valley, CA; Jim Esther of Pasadena, CA; Dennis W. Fera of Fayetteville, NC; Morton H. Field of Beverly Hills, CA; V. L. Fisher of Bowling Green, KY; John F. Floyd of Spokane, WA; Mark Fox of Crossville, TN; Alan M. Freedman of Great Neck, NY; C.B. George of Tampa, FL; Gary Gillespie of Williamston, MI; Ralph Giorno of Denver, CO; W. Lloyd Glover, Jr. of Fairfax, VA; David Goldstein of Westwood, NJ; Terry Greene of Mt. Airy, GA; Eugene E. Gregush of Port Charlotte, FL; Rosemarie Guistillo of Hagerstown, MD; Harry T. Haramis of Dayton, OH; Ed Hartzler of Seattle, WA; Philip D. Hellreich of Kailua, HI; Edward Hoffman of Olympia, WA; Tim Hulsey of Bowling Green, KY; William E. Hummel of Everett, WA; Judith Ing-Higushi of Renton, WA; John T. Joseph of Renton, WA; Harry M. Katz of Cedar Hill, MO; Hose Kim of Whittier, CA; Bert O Kjos of Mercer Island, WA; Robert Klein of Mercer Island, WA; Harvey Klein of New York, NY; Eric Kohler of Seattle, WA; Deepak Kumar of Dayton, OH; J. Lautersztain of Tampa, FL; Stephen Ley of Bozeman, MT; L. Gie Liem of Oakland, CA; R. H. Lofton of Port Arthur, TX; J. Patrick Lynch of Everett, WA; Robert E. Maloney of Spencer, MA; Donald Lee McCabe of Freeland, WA; Lyles Mindlin of Bowling Green, KY; Richard W. Most of Mt. Kisco, NY; Alan Muraki of Bellevue, WA; Roy Naturman of Morristown, NJ; John Okun of Brandon, FL; Robin Oshman of Westport, CT; Samuel Packer of Great Neck, NY; Jeff Pearce of Bellevue, WA; Michael D. Perkins of Oneida, TN; Jose L. Pino y Torres of Maitland, FL; Dale R. Pokorney of Hermitage, PA; James E. Preston of Sandusky, OH; Lewis A. Raney of Dallas, TX; Holly Reid of Stamford, CT; Elaine Remmers of Tucson, AZ; Pierre Rioux of Minot, ND; Victor M. Rodriguez of Port Charlotte, FL; Mort Shahmir of Bowling Green, KY; Paul Sicuro of Seattle, WA; Lee J. Skandalakis of Atlanta, GA; Ronald Skufca of Dallas, TX; Joann Somers of Livingston, NJ; Firth Spiegel of Livingston, TN; David Stewart of Hillsdale, NJ; Robert A. Sylvester of Lewiston, ME; E. Terry Tatum of Bowling Green, KY; Joe Thomas of Seattle, WA; Edward R. Thomas of Dayton, OH; John Thompson of Seattle, WA; Paul M. Tuffers of Renton, WA; Sui M. Twe of Kent, WA; William Unis of Bronxville, NY; Peter Utrata of Columbus, OH; Phil Vogelzang of Seattle, WA; Allan R. Warren of Port Jefferson, NY; J.D. Wasnick of Dallas, TX; Richard J. Wiesemann of Bowling Green, KY; Joseph M Worth of Clearwater, FL; John A. Young of La Jolla, CA; and Alan Zend of Edmonds, WA. Nancy Tsai of Seattle, WA, is a new student member.


Meetings to Focus on Private Contracts, Reform

At the May 22 AAPS meeting in Sarasota, FL, Drs. Michael Schlitt of WA and Lois Copeland of NJ (physician plaintiff in Stewart v. Sullivan) will report on their experiences in contracting with patients privately outside of Medicare. AAPS Counsel Kent Masterson Brown will provide an update on litigation concerning private contracts, including the prospects for challenging state legislation.

John Thrasher, attorney for the Florida Medical Association, will explain the ``managed competition'' legislation recently passed by the Florida state legislature. This could be a preview of the Clinton Plan.

The meeting is scheduled for 7:30 a.m. until noon (see calendar). The charge is $35.

A grassroots effort to promote free-market solutions to the medical insurance crisis will be the theme of a national meeting in Dallas June 18-19. A number of physicians' organizations, including AAPS and Dallas-based Physicians for Patient Power, will participate. If you wish to attend, let Dr. Francis Davis (publisher of Private Practice) know immediately (405-273-6124).


AAPS Calendar

May 22. Board of Directors meeting and medicolegal seminar, Bradenton/Sarasota, FL, Hyatt Hotel and Sarasota Garden Club. Call 1-800-635-1196 to register and 813-366-9000 to make a hotel reservation.

Oct. 5-9. 50th annual meeting, San Antonio, TX.

Legislative Alert

Presidential Task Force Struggling

While Hillary Rodham Clinton's task force, over 500 strong, is struggling with leaks and lawsuits, its internal debates are focusing on two critical areas: the workability of global budgets and price controls and the revision of the tax treatment of health care benefits.

The President has repeatedly stated that he wants a health care plan loosely based on the concept of ``managed competi- tion,'' i.e. ``price competition'' among geographically based managed-care plans, offering the same or at least similar benefits packages, within a new regulatory framework for employer-based insurance. Managed-competition advocates want competition to be focused on quality and price, not benefits; thus their heavy regulatory restrictions on the insurance markets. Managed competition, it should be recalled, was largely developed by Professor Alain Enthoven of Stanford University and Dr. Paul Ellwood, the leader of a group of intellectuals called the Jackson Hole Group. The biggest financial supporters of the Jackson Hole Group are, not surprisingly, big insurance companies, the very group that is likely to benefit from the limited and restrictive market envisioned in a managed competi- tion model.

But the original managed-competition model is precise, intricate in detail, and dependent upon very specific changes in both the tax and the regulatory regime governing health in- surance. If you take away key nuts and bolts, or turn them in the wrong direction, the ``managed competition'' machinery simply will not work as intended. Enthoven's plan is inherently unsuitable for being fed into the sausage factory on Capitol Hill.

Among the ideas that are being shredded in the meat-grinder:

  • Taxing health benefits or the value of benefits above a specified amount to encourage prudent purchasing: En- thoven has repeatedly stressed that managed competition simply will not work without the tax changes. But Hillary Rodham Clinton, according to a February report by staff writer Edwin Chen of the Los Angeles Times, told an unnamed health advisor that ``there's something more important than having prudent purchasers, and that's called getting re-elected in four years.''

  • Price competition: If the absence of price competition is what is wrong with the system, then price fixing (as by extending the huge and cumbersome DRG and RBRVS regulatory machinery to the private sector) is obviously not the way to solve it.

  • Incentives: As Enthoven, Ellwood, and conservative House Democrats have pointed out, even a ``managed'' market is incompatible with global budgets. A global budget calls not for incentives but for enforcement. Who will do the enforcement, and how? What do you count in the global budget? How do you gather the necessary data?

At the same time, the Task Force is charged with keeping the campaign promises out of the shredder:

  • Guaranteed access to a basic system of health benefits for all Americans, including pregnant women, children, and the unemployed;

  • Enforcement of an employer mandate;

  • Eliminating tax breaks for pharmaceutical companies that raise prices faster than increases in family income;

  • Eliminating restrictions on the purchase of medical insurance for pre-existing condition;

  • Reforming claims processing.

What seems to be emerging is a catch-all expansion of the current employment-based system, an unsound, inflationary market which is already riddled with regulatory-driven inefficiencies. This will be require another big tax increase to finance expanded access for the uninsured, which will of course drive costs up, combined with the imposition of global budgets and price controls, which are designed of course to drive costs back down again, at least partially. This will be sold as ``cost containment.'' In other words: we are likely to see a policy mess that will be ``managed competition'' in name only.


Who Are the Players?

Now that Congressman Jerry Solomon (R-NY), the Wall Street Journal, the Washington Post, the Washington Times, the New York Times, and others have all published the names of the 500-odd members of Hillary Clinton's heretofore top secret task force, the key question around Washington is: How many do you know? Beyond the Washington Beltway, the names are mostly a mystery. Inside the Beltway, the names are all too familiar, and about the best indication we have gotten yet about where the Task Force is going to come down on some key issues.

There are not very many ``New Democrats.'' A total of 81% are full-time federal employees, disproportionately coming from two groups, Congressional staff and bureaucrats from OMB and HHS, HCFA in particular. HHS careerists include Kathy Buto, Director of HCFA's Bureau of Policy Development; Ross Arnett, HCFA's Director of the Office of National Health Statistics; and Barbara Gagel, Director of HCFA's Health Standards and Quality Bureau. The HHS political appointees include Judy Feder, formerly director of Clinton's health transition team; Ken Thorpe, also an early transition team member; and Brookings Institution scholar Josh Weiner. The rest, 19%, are part time feds and consultants.

The whole secrecy business has been a big public relations mistake for the Administration. The attempt to cover up such a huge domestic policy effort only makes even the liberal pressies, who likely voted for Clinton and the Democrats, even more curious and potentially hostile. What's the point of all the somber secrecy anyway? To protect these 500 or so delicate flowers from the intrusion of ``bad'' special interests (like (physicians' groups) rather than the ``good'' special interest groups like the Children's Defense Fund?

Hillary's Task Force is packed with liberal, often young, Democratic Congressional staff. But there are also some senior Hill staffers who are likely to have a big role when the Hillary Health Plan hits Capitol Hill: Ed Gleiman, who works for Sen. John Glenn (D-OH) as top staff aide on the Senate Government Relations Committee; Karen Nelson, a top staff aide from Rep. Henry Waxman's House Subcommittee on Health and the Environment; David Nexon, who works for Sen. Ted Kennedy (D-MA) as Staff Director for the Senate Committee on Labor and Human Resources; and Gail Weiss, staff director of the House Post Office and Civil Service Committee. Other legislative staff members include aides from the offices of Sen. Patrick Leahy (D-VT), Sen. Jay Rockefeller (D-WV), Sen. Bob Kerrey (D-NE), Sen. Jeff Bingaman (D-NM), Sen. Harris Wofford (D-PA), Sen. Bob Graham (D-FL), Sen. Max Baucus (D-MT), Sen. Daniel Patrick Moynihan (D-NY), Sen. David Pryor (D-AR), Sen. Herb Kohl (D-WI), Sen. Donald Riegle (D- MI), Sen. Barbara Mikulski (D-MD), Sen. David Boren (D-OK), Sen. Tom Harkin (D-IA), Sen. Bill Bradley (D-NJ), and Sen. Howard Metzenbaum (D-OH).


Congressional Jockeying

Although Senate Majority Leader George Mitchell, a once and future advocate of employer mandate, advocated packaging the Hillary Health Plan together with the gigantic tax and budget proposal for a straight up-or-down vote, others have cautioned against taking a plunge over domestic policy's Niagara Falls. S- en. John Chafee (R-RI), for example, is calling for a slower pace on the legislative front. Translation: Remember the painful Medicare Catastrophic Coverage Act of 1988, repealed again in 1989.

Well before the Administration has put its plan on the table, liberal Democrats are trying to shift the ground of the coming debate, pressuring the firm of Clinton and Clinton from the left. While the Administration asked Congressional Democrats to refrain from introducing any health care policy bills until it had laid its own plan on the table, Congressman Pete Stark (D- CA), Chairman of the House Ways and Means Subcommittee on Health, flatly ignored the White House plea and put his own bill on the table, basically an expansion of Medicare for everybody. In another interesting twist, Congressman Gary Ackerman (D-NY) has introduced a bill (HR 45) that would abolish the broad and ``bewildering'' consumer choice and competition in the Federal Employees Health Benefits Program (FEHBP), and replace it with a single plan, with a high option and a low option, plus some geographically based HMOs, price controls, a new federal employees health benefits board, and a tax-free ``flexible spending account'' thrown as a bone to Congressional conservatives. While obviously not a comprehensive reform proposal, Ackerman is careful to note that his bill is compatible with the Administration's proposed ``managed competition''- which should tell us something.

Likewise, Congressman Jim McDermott (D-WA) and 58 House Democrats have introduced the ``American Health Security Act,'' basically a rerun of the Canadian-style single payer bill authored by former Congressman Marty Russo, the Chicago Democrat defeated in the 1992 primaries. Just like last time, the chief proponent of the single payer system to emerge in the Senate is Sen. Paul Wellstone (D-MN). This leaves the conservative Democrats, the Congressional champions of managed competition, led by Charles Stenholm (D-TX) and Rep. Jim Cooper (D-TN), in an increasingly awkward spot. They are behaving themselves as loyal Democrats, as politely requested by the White House, while their own intellectual allies on Hillary's Task Force, backers of the ideas of Enthoven and the Jackson Hole Group, are getting savaged and sidelined by the price controllers and the global budgeteers.

If liberal Democrats in Congress, who really want a Canad- ian-style system, are easy to understand, Congressional Republi- cans remain a genuine political mystery, the Case of the Meandering Mainstream. In the House of Representatives, after months and months of deliberations by a special health care task force, House Republicans still have not surfaced a comprehensive health care reform bill, at least nothing that will seriously compete with the massive legislative vehicle that Bill and Hillary, with the full backing of the Democratic National Committee, is likely to throw at them in a matter of weeks. In spite of over two centuries of American legislative experience, some Republicans still think that you can fight something with nothing.

Republicans will either have to fight or fold. For moderates and liberals, the ideal scenario seems to be friendly bipartisan negotiations over technical differences in their respective ``managed competition'' proposals: the Washington ``process'' of wonk work into the wee hours, with a ``a seat at the table'' far more important than the substance of the outcome. The basic idea: Senate Republicans will get some of the political credit for ``doing something'' about health care reform. No real debate of opposing principles. No real shots fired.

Senate GOP leaders look as if they are headed for preemptive surrender. Sen. Chafee has been explicit on the point, saying that he wants a proposal that can ``jibe'' with what the Clinton Administration is likely to come up with in May. Even going so far as to use Clinton's rhetoric, Chafee is now saying that the American people have got to be prepared to ``sacrifice'' in order to make health care reform successful. What do they have to sacrifice? On March 11th, the Rhode Island Senator told his colleagues on the Senate floor: ``..in summary, Mr. President, we should and indeed will have health care reform in our country. But at the same time, it behooves all of us to be very, very candid with our constituents....There will indeed be coverage for everyone after a while, but...some regulation is going to have to come into the lives of our constituents who are enjoying fee- for-service type of medical care where they can go to any doctor they want to, any hospital they want to. That, to a great extent, will no longer be possible.''

Organized Medicine Marches

Like the proverbial frogs in a long simmering pot, a lot of doctors are now dimly aware of the heat. Snubbed by Hillary and Co., the American Medical Association (AMA) is now busing the doctors up to Capitol Hill to argue against price controls and fee caps in the private sector and other intrusions.

But, there's a political rub. Virtually every representative group of organized medicine (except AAPS) has issued position papers calling for even more, not less, government control over American medicine. Furthermore, members of Congress, many of whom are sympathetic to the plight of small businesses, are hearing from too many doctors that it is perfectly legitimate to regulate other private businessmen or other sectors of the medical economy, as long as doctors are exempted from further burdens. The AMA, the American Society of Internal Medicine (- ASIM) and the American College of Physicians (ACP) have all backed proposals to force small employers to purchase medical insurance for their employees.

If physicians are so indifferent to the struggles of businessmen who are trying to recover from a long recession, why should they expect sympathy for themselves?

As the heat is turned up further, will organized medicine even notice?

Will physician leaders win smiles and photo-ops in the Rose Garden as the President signs into law the most massive ``health- care reform'' in the nation's history? Or will they sacrifice their patients' (and all Americans') long-term best interests, only to become road-kill as the Clinton public-relations buses roll into action?