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Let the Elderly Lead the Way. I pay $30 per month for Medicare Part B, and the taxpayer pays $100. That is over $1000 per year....The sheer truth is that special interests obtain subsidies for the aged, farmers, manufacturers, and so on....

Let us turn a new page in American history: repeal Medicare. It will then be necessary for the elderly to buy what insurance they can afford. Because it was third-party payers that caused the inflation in medical costs in the first place, we will immediately have cost containment. Everybody will get the message, including we elderly, that we must be responsible in our demands, and the providers in their demands.

None of us elderly want to pass on to our grandchildren, whom we dearly love, a $4 trillion debt.
Robert J. Madden, Ph.D., M.D., Waterford, MI

``Management'': Liberal Democrats have been misleading people to believe that government-promoted managed-care programs will allow them free choice of doctor....Nothing could be further from the truth. According to an article in the Spokesman- Review (Spokane), a rule adopted by the Washington State Health Services Commission will allow insurance companies to turn away ``providers'' even if they meet insurers' guidelines. And under Washington's ``health-care reform,'' fee-for-service billing will be outlawed, and all patients will be served under managed-care plans.

Blue Cross in the Washington, DC, area has taken cost containment to an even more restrictive level by not allowing any neurologists to participate in their managed-care program. By managing to exclude all specialists, Blue Cross claims to save money-at the expense of the patients.
Lawrence R. Huntoon, M.D., Jamestown, NY

Revival. A letter to Mr. Robert E. Allen, CEO, AT&T:

AT&T Telephone Pioneers could show a way to avoid impending entitlement disaster, by modeling Medisave in Medicare.

Individually shopped health services (funded with present health benefits transferred to medical savings accounts + umbrella) could save 64% of previous costs-and for better care. Golden Rule Insurance Company employees experienced this. Milton Friedman predicted this.

Your directive for a health benefit option like Golden Rule's would revive initiative and responsibility in AT&T retirees and employees. This directive now would promote U.S. Congress actions liberating individuals from government oppression and from insurer micromanagement of their lives....
Howard F. Long, M.D., M.P.H., Pleasanton, CA

Milton Friedman, Hoover Institution

[Mr. Friedman in a separate letter made note of the enormous prior-conditions problem of those who are 82 years old and have been in Medicare for many years.]

HMOs Are Like Fruit Baskets. Employers select some of these baskets and offer them to their workers who must choose which basket they want. Years later, if and when workers become patients, these HMOs restrict patient's choices....Even if over the course of time some of the fruit has rotted, patients cannot change baskets....Physicians may have to consult with inferior physicians and use inferior hospitals in order to practice medicine....

Employer mandates would continue our current move toward HMOs, yet the media are strangely silent on the awesome power of taxes that spawn this move....To save tax dollars, workers choose tax-deductible premiums over out-of-pocket medical care paid with after-tax dollars. This is unfair. As long as employer-provided premiums are tax-deductible, the IRS should allow patients to deduct their out-of-pocket medical expenses and patient-paid insurance premiums....
Bert A. Loftman, M.D., Atlanta, GA

Ethical Foundations [excerpted from a letter rejected by the AMA]. I am very disturbed by the 4/20/94 JAMA ``Special Communication's'' distortion of the ``moral traditions we share as a nation'' being used to justify the greatest departure from this tradition ever proposed....Our government's purpose was not to provide us with rights and entitlements by taking from each according to ability to pay, and distributing to each according to need....The government was rather to ensure minimum interference with the individual's right to better himself. Relinquishing to the government the individual's responsibility of ``wise allocation...[of] resources between health care and other important goods such as education and housing'' is not a traditional American value.
Harold J. Kornylak, D.O., Virginia Beach, VA

AAPS Calendar

Oct. 12. Board of Directors meeting

Oct. 13-15. Ritz-Carlton Hotel, Atlanta: 51st annual meeting of AAPS. Registration form enclosed: Last Chance!

Oct. 29. Freedom in Medicine meeting, Augustana College,

Sioux Falls, SD. Topics include: Criminalization of medicine (Brad Smith, Capital Univ.); medical savings (Lee Tooman, Golden Rule Insurance Co., and Merrill Matthews, NCPA); constitutional foundations (Jonathan Van Patten, Univ. SD). Also speaking: Ed Annis, Bob Moffit, and John Del Giorno. Call (419)668-8282 to register or to arrange a F.I.M. seminar in your area.

Legislative Alert

Recall that we had previously likened the national health care debate to the domestic policy equivalent of the Battle of Gettysburg. Clinton's several public relations offensives had failed and the only thing was a last, desperate gamble in the House or Senate, some political equivalent of Pickett's charge. The difference: Poor General Pickett was at least able to form ranks and march off to immortal Glory. The House Democrats can't even form up their ranks for the big showdown.

``The vote counts show so many Democrats opposing the Gephardt bill that the White House officials recently urged their allies outside government not to compile or distribute such lists for fear they could be used to undercut people lobbying for an employer mandate,'' writes Robert Pear (NY Times, 8/25/94).

The Meandering Mainstream Mess

For those who fear the establishment of government- controlled medicine, this is a period of maximum danger.

After a big, tough fight on the Crime Bill, Senator Majority Leader George Mitchell has sent his exhausted colleagues home. His huge 1,443 page health care reform bill, the latest Senate version of the Clinton Plan, cannot pass the Senate. Mitchell knows it. He also knows that he has nothing to lose. This makes him politically a formidable opponent for Senate Republicans and conservative Democrats.

Mitchell's bill is a case study in the Non-Clinton Health Care Reform category. Mitchell, his Senate allies, and even the White House, have advertised the bill as less bureaucratic, less costly, and less intrusive. Some supporters have even called it a ``market-oriented'' plan. (Recall in 1993 that HHS Secretary Donna Shalala called the Clinton Plan a ``conservative plan''- Chutzpa has lost its meaning with this crowd.)

None of this seems to have worked. The Mitchell bill, in some respects, is even worse than the Clinton original. Senator Arlen Specter, the author of the nationally famous chart on the Clinton Plan, has gone back to the kitchen table to plot out the new federal departments and agencies created by the Mitchell bill. The result is more of the same.

This fight is far from over. Too many Congressional opponents of the Clinton Plan may be celebrating prematurely. Look for desperate action on the part of the White House allies in the Senate to get any Senate bill to pass, with the intention of taking it into conference with the far more liberal House leadership, where work can begin once again in the congressional back rooms on resurrecting the key regulatory components of the increasingly unpopular Clinton Plan.

Senator John Chafee (R-RI), has been drafting and redrafting legislation for the Mainstream Coalition, a Senate group of self- described ``moderates'' who want a ``middle of the road'' solution to the legislative impasse. The bill contains the infrastructure for a government-controlled health care system: a national commission with a lot of power to collect data (no need to collect data unless you can act on it-if not now, later); a comprehensive government standardized benefits package; new federal insurance regulations; and new subsidies for low-income working Americans.

On August 18th, the Senate Mainstream Coalition was on the verge of breaking up; on August 19th, they were wrestling over specifics, trying to find consensus on the damnable details. Now, they are meeting with Senator Mitchell's staff.

In the meantime, Robert Reischauer of the Congressional Budget Office (CBO), an equal opportunity dispenser of Bad News, met with the group to discuss costs. After the CBO cold shower, the Mainstream Coalition refocused its efforts to make sure that the evolving bill would meet the goals of cost control and deficit reduction. So, it ended up with a new prescription for more taxes and new Medicare cuts. Just the right formula for the Washington Office of AARP perhaps?

Legislative Implosion?

Their behavior on the ``health care'' issue threatens to shred what little credibility remains for the Clinton White House and Members of Congress.

1. Nothing's Exactly What You Think It is. Whatever one thinks about the Clinton Plan, it is not a mystery. It is huge. It is complex. It is tedious reading. Trying to interpret some sections would try the patience of a Talmudic scholar. But it is all there. It has been subjected to independent econometric analyses, including the staff analyses of the CBO, the large econometric firms such as Lewin/VHI and the CONSAD corporation, Peat Marwick and the American Society of Actuaries, as well as legislative analyses from just about every major public policy institute from the Brookings Institution to the Heritage Foundation. It has been the subject of charts and radio and TV commercials, for and against.

The Clinton Plan drives Members of Congress into fits of fear and loathing. Compulsory alliances, price controls, premium caps, big batches of bureaucracy, boards, panels commissions, rules, regulations, fines, the works. Nobody on Capitol Hill wants to bring the unpopular Clinton Plan to the floor for a straight up-or-down vote. The largely unreported humiliation of the White House in the House Ways and Means Committee early in the summer, where not one Member voted for the President's Plan when the Republicans put it up for disposition, is an indication of the Congressional leadership's deeper problem. In fact, the Clinton Plan is so unpopular with the public that the initial appeal of other proposals is simply that they are Not the Clinton Plan. (The Cooper-Grandy Managed Competition Proposals and the Rowland-Bilirakis proposals come to mind.)

So what to do? Repackage the Clinton Plan, rearrange its parts, give it a new set of tires and a paint job, polish the chrome and try to sell it to an increasingly skeptical public as something really different.

Hillary and Company continue to complain that they are victims of greed, disinformation, fear, and paranoia. Clinton spokesmen insist, still, there are no price controls in their bill (only ``premium caps''); it's not really bureaucratic; it will even mean a ``net reduction'' in regulation; universal coverage now means 95 percent, not really 100 percent coverage, etc. etc. Provisions are explained as good for us, but, upon closer examination, the details are not exactly what we thought.

For example, on August 3, during his national press conference, the President said that he was encouraged by the Mitchell bill and other developments, including the proposal to open up the Federal Employee Health Benefits Plan (FEHBP) to the general public. With a straight face, he stated that he had ``always'' favored opening up the FEHBP to the general public. Not exactly. His own bill abolishes the FEHBP.

In this peculiar debate, broad concepts, positive sound bites, nifty slogans, or attractive labels mean nothing; the details mean everything. That is why Congressman Pete Stark (D- CA) is beating the drums for fast Congressional action: any delay would be disastrous because opposition will build. So make sure to vote something before the folks back home get wind of the details. Hillary Clinton, complaining of legislative scrutiny in the 1990's, notes that Franklin D. Roosevelt didn't have to defend ``every jot and tittle'' of the his agenda. Lucky guy, that FDR. Today, a liberal bill becomes the legislative equivalent of a fish: longer exposure to the sunlight doesn't make it smell any better.

2. Legislative Confusion. After George Mitchell introduced his gargantuan 1,410 page bill on August 3rd, he felt compelled to rewrite it. On August 9th, yet a new version of the Mitchell bill appeared. In Title I alone, Mitchell had modified 33 sections; in Title II, six sections and one subtitle; in title III, 28 sections; in Title IV, 13 sections; Title V, 15 sections; Title Vi, 6 sections; Title VII, 5 sections; Title VIII, IX, and X, subtitles; and in Title XI, the whole thing was modified. But that was not enough: on August 12th, Mitchell submitted yet another version of his bill, weighing in at 1,443 pages. Like the river of Heraclitus, the Greek philosopher, the huge Mitchell bill is not in being, but rather in state of flux, in a constant state of becoming.

Normally, in a committee mark-up, the Committee starts from a working draft of a bill, and the provisions are discussed and amended, line by line, and the changes are made to the statutory language, the legislative concepts are clarified, and a legislative history is fashioned in the process. Working from carefully crafted legislative language, a product of the Legislative Counsel's office of the House or Senate, the Members of the Committee then write a report for their colleagues, outlining in English and in some detail exactly what the bill does. So, when there is full debate on the Senate floor, everybody is crystal clear about the language and what the implications are for the country.

But not in this issue that directly affects the personal lives of over 257 million Americans and a huge and highly complex sector of the American economy.

The Senate Finance Committee is working, not from legislative language, but from rough legislative concepts, like insurance market reform, or purchasing alliances, or whatever. After the Committee votes on vague ideas, the staff is supposed to draft the statutory language. The end result of the backwards process is that the staff's legislation does not represent what the Members had in mind. Also, there are no independent budget estimates and no independent analysis. Indeed, after the Senate Finance Committee draft was finalized by staff, the Congressional Budget Office (CBO) pronounced large parts of it unworkable. Yet, much of the Finance Committee bill has become the mainstay of the Mitchell Bill.

Thus the Congress is erecting, haphazardly, what one Capitol Hill wag called a grotesque monument to the Law of Unintended Consequences.

3. The Politics of Government Control. It's clear that the health care debate now has less to do with the problems of medical care, which are fixable for most Americans, and everything to do with the restoration of the Clinton Presidency and the preservation of the huge liberal majorities in Congress. In short: it's about survival in November.

The Senate liberals want to paint the Senate Republicans into a corner. It is a simple strategy. Either get the Republicans to accept the Clinton Plan, or some variant of it, which will put into place all of the objectionable regulatory elements of the Clinton Plan, either immediately or on a delayed basis. Or force them to filibuster and pay the political price for delaying reform. For Clinton Democrats, its a win-win situation.

The latest gambit by Senator Mitchell is to drop his own bill and try to forge an agreement with Chafee and the ``Mainstream.'' Insiders on Capitol Hill think that the retiring Mitchell will do just about anything to get to Conference.

If Republicans filibuster, they can be accused of ``Gridlock,'' the mortal sin of the Majoritarians. Conservatives on Capitol Hill are looking at another tactic. Instead of a debate on the Clinton Plan, force debate on any or all of the components of the Clinton Plan. Give the Democrats their 51-vote victory if that is what they want, but force individual votes on all of the key components of the Clinton Plan: the creation of the national health board, the standardized benefits package, the compulsory funding of abortion, the erection of mandatory health alliances, the imposition of premium caps and price controls, the tax increases required to cover shortfalls in deficit or the subsidies, every fee or tax increase, and then get out of the way. Allow the Congressional liberals to take up-or-down credit for all of these features and go explain themselves to the folks back home.

Traffic Jam on the Information Superhighway

When the history of the national health care debate is finally written, observers will find an ironic twist to the proceedings. Vice President Gore has been a champion of the Information Superhighway, the vast network of computer chips, faxes, and fax modems. With the information industry's ability to process information doubling every 18 months, the political process has barely been able to compete with the diffusion of detailed data. In short, Hillary's health care bill was literally run over by the facts and analyses racing across country on the emerging Information Superhighway.

In the old days, lobbyists and lawyers would grab their legal pads and one of a limited number of copies of bills. They could push modifications with friendly staffers over a few drinks after work in one of Washington's numerous watering holes. But no more; a bill, including a very big four-and-a-half pound bill, can be put on a disk. And then there are the reports, econometric analyses, and the studies; they too can be accessed on the information superhighway. And the stuff is picked up by Talk Radio, the interactive and combative media, where the Washington Establishment is forced to explain itself. And as for Congressmen, they are being forced publicly to answer questions at their Town Hall meetings back home that are more pointed and specific than the kinds of broad inquiries they used to get back in the good ole days. The pricey lawyers and the lobbyists and the old entrenched crowd inside the Beltway now find themselves outflanked and immediately on the defensive. The painful process of the national health care debate could be signalling the beginning of something really Big. Maybe, just maybe the Washington Establishment of the 1990s is falling victim to the awesome power of the computer chip. Information abounds. And the truth, as Scripture promises, does indeed make us free.