If these facts surprise you, it's because you haven't been given a straight story about the Clinton health bill. Take two examples: on November 4, Leon Panetta, the director of the Office of Management and Budget, testified to senators that the bill does not "set prices" and "draw up rules for allocating care"; a month later Hillary Rodham Clinton assured a Boston audience that the government will not limit what you can pay your doctor. The text of the bill proves these statements are untrue.
The administration also says that the bill will not lower the quality of your medical care or take away personal choices you now make. This statement goes right to the issues that matter most. How true is it? To help you decide, here is a guide to the 1,364-page Health Security Act.
No effort is made here to compare the Clinton bill with the many alternatives offered by Republicans and other Democrats or to assess the nature and extent of the health care "crisis." The purpose is to answer one question: Under the Clinton bill, if you become ill, will you be able to get the treatment you need and make choices about your own health care?
The Law Will Make You Get Health Care Through Your "Alliance." Under the bill, unless you get Medicare, military benefits or veteran's benefits, or you or your spouse work for a company with more than 5,000 employees, you must enroll in one of the limited number of health plans offered by the "regional alliance" where you live (page 15). Regional alliances are government-run monopolies that select health plans, collect premiums from residents and their employers and pay most of the money to HMOs and insurers. If you fail to enroll, or the plan you choose is oversubscribed, alliance officials will assign you to one (pages 144, 146). The goal is to curb health care spending by limiting what every American is allowed to pay for health insurance. Restricting how much people can pay for insurance limits how much money is in the pot to take care of them when they're sick.
The Health Care You Can Get Will Be Limited. Under the bill, a National Health Board--seven people appointed by the president--will decide how much the nation can spend on health care beginning in 1996 (the baseline year). Based on that national budget, the board will set a budget for each region and a ceiling on what the average health plan in the region can cost. The bill outlaws plans that would cause a region to exceed its budget or that cost over 20 percent more than the average plan. After 1996, increases in health plan premiums will be strictly limited by an "inflation factor" based on the consumer price index (pages 256, 984-987, 990, 995).
Putting price controls on premiums to limit the amount of money in the health care system might wring out waste during the first year or two, but there is no doubt it will cause hardship later on. Seventy-seven million baby boomers will be reaching the age when they need more medical care. Increasing numbers of teen pregnancies and low-birth-weight babies also will require more health care dollars--$158,000 on average for each severely underweight newborn. Even the bill's authors anticipate that restricting the dollars available for health care in the teeth of these trends will produce grave shortages: the bill provides that when medical needs outpace the budget and premium money runs low, state governments and insurers must make "automatic, mandatory, nondiscretionary reductions in payments" to doctors, nurses and hospitals to "assure that expenditures will not exceed budget" (pages 113, 137).
Above a threshold level of quality, alliance officials will approve health plans based on lowest cost, not highest quality, to stay under the premium ceiling set by the National Health Board, explains Cara Walinsky of the Health Care Advisory Board and Governance Committee, which advises 800 hospitals worldwide. That is why Anthony L. Watson, chief executive of the Health Insurance Plan (hip) of Greater New York, is optimistic. If the Clinton bill passes, "New York is mine," he told The New York Times. "I'm going to be the lowest-cost plan." hip, with a physician staff that is 57 percent foreign-trained, already has what that newspaper calls "the image of being the least desirable health care option for city workers and others who cannot afford anything more."
Staying With the Doctors You Use Now Will Be Hard. Deciding for yourself when to see a specialist or get a second opinion and selecting the hospital you think is best will be even harder. The bill is designed to push people into HMOs, which restrict your choice of physicians and hospitals, and use gatekeepers to curb the use of specialists, expensive tests and costly high-tech treatments. What most of us call fee-for-service (choose-your-own-doctor) insurance will be difficult to buy. The ceiling on premiums and the 20 percent rule will eliminate most fee-for-service plans, which tend to be more expensive than their pre-paid counterparts. Although the Clinton administration insists that Americans always will be able to choose fee-for-service insurance, experts such as Dr. John Ludden, medical director of the Harvard Community Health Plan, say that option will "vanish quickly."
Even where it is possible to buy fee-for-service insurance, it will be hard to find doctors practicing on that basis. According to Walinsky, the Clinton proposal contains "very strong incentives" against fee-for-service "on the consumer side but also on the provider side." Price controls on doctors' fees and other regulations will push doctors to give up independent practice and sign on with HMOs. We've been told that the government won't be putting price controls on doctors, but the bill limits what health plans can pay physicians and prohibits patients from paying their doctors directly. Alliance officials post a schedule of fees, and it is illegal for doctors to take more (pages 134, 236).
In addition, alliance officials set yearly limits on payments to fee-for-service doctors in each field of medicine, like cardiology or pulmonology. What if a flu epidemic causes pulmonologists to see more patients with breathing problems than the region's budget allows? The bill compels insurance plans to slash doctors' fees or cut off their payments entirely until the next year "to assure that expenditures will not exceed the budget" (page 137).
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