The bottom line on health reform.

• Author: Meacham, Jon

All the elements are in place for a classic Washington minuet on health care: Mitchell and Foley shuttling between the White House and Capitol Hill; Moynihan expounding on the Sunday morning shows; Clinton cajoling lawmakers; then, in the end, C-Span televising the vote on the Health Security Act of 1994. The president will hail the achievement in the Rose Garden, and the congressional satraps will then run home to campaign.

First, the setting: The Democrats want to pass a health care bill this year--any bill. After George Mitchell led a Colonial Williamsburg retreat of Senate Democrats in late spring, he came back saying, "There was no discussion of timing, except we intend to get it done this year." On the plane back to Washington from Nixon's funeral in California, Bob Dole organized an all-night health care talkathon.

But the terrifying likelihood is that what emerges will fall far short of the reform the country needs. This is especially true if the legislative winner is a limited bill that merely takes care of the two things the middle class thinks will solve its insurance worries: eliminating denial of coverage if you have a preexisting condition and guaranteeing you won't lose insurance if you switch jobs. It this happens, then the constituency for major health reform could become like that for deficit reduction or for aid to the poor--the pious and the concerned, and history tells us they don't often make up a working majority.

Instead, we will go on spending nearly $1 trillion annually, billions more than any other industrialized democracy, on a health care system that, unlike any other democracy, leaves millions uninsured and still millions more worried that they cannot pay medical bills, insured or not--in sum, a confused and angry public spending too much money and not getting what it wants in return.

But insurance reform, while important and no doubt politically appealing, won't be enough. In Washington the temptation is growing to do whatever it takes to get a bill, even one that could prove inadequate. "There is a sense that this is closing in--all the years of meetings and all the studies and all the speeches," says Jay Rockefeller.

On May 4, for example, Democrats Bob Kerrey and David Boren endorsed Republican John Chafee's bill, which has no reliable mechanism for controlling overall costs, creates new bureaucracies, and delays universal coverage until the 21st century. Nevertheless, the step was hailed by Washington voices with a stake in keeping reform to a minimum.

"This is the most significant break-through all year in moving Congress toward action," said Bill Gradison, head of the Health Insurance Association of America. Well, yes, if you consider firmly entrenching private insurers at the heart of an already-complicated health care system and delaying universal coverage for a decade "action." But the tom-toms are beating: A Washington Post headline declared: "Chafee Bill: A Dose of Compromise." A Democratic campaign strategist told The Washington Times, "Democrats cannot afford to let this go on until the bitter end. We have to have health care in hand to take home to the voters." Apparently so: On May 10, Ted Kennedy, long a backer of major health reform, proposed eliminating the critical Clinton health purchasing alliances in order to get a bill out of his Senate Labor and Human Resources Committee. And the president summoned the Democratic leadership to a May 24 White House meeting to see what has to be done to make a deal this year.

But history is unmistakable on this point: Legislative rush jobs near an election often produce near-fatal to fatal compromises. (Exceptions are the historic Congresses of Roosevelt in 1933-36 and of Johnson in 1964-66.) Frequently what appear to be reasonable concessions--in this case, just reforming insurance, for example--are in truth fatal flaws. The 1986 Tax Reform Act, for instance, despite its announced aims, neither radically simplified the nation's tax system nor made it fairer by dramatically increasing the amount of income subject to federal tax. Likewise, the promised total welfare reform of the Family Support Act of 1988--Daniel Patrick Moynihan warned then that "we put the next century at risk" if the bill didn't pass--failed to match its ambitions and here the nation is again debating how to end welfare "as we know it."

To be sure, we wish the Clintons had used a Canadian-style single payer system as a working model for health reform. Contrary to the popular impression that single payer is some kind of horrifically statist enterprise, it is in fact the most attractive and least disruptive of the reform plans that are on Washington's table. How? Because single payer largely eliminates the key villain that makes most people unhappy with or nervous about their health coverage: costly insurers. It also covers everyone at equal levels of decent care, controls costs, guarantees doctor choice, and is mainly financed by income and sales taxes, not a potentially burdensome employer mandate or a hopelessly complicated individual one.

But the Clintons--and enough congressional Democrats--instead embraced the untested and more complex theory of managed competition. (Congressman Sam Gibbons summed up Washington's attitude toward single payer: "It just won't fly.") Managed competition enhances the role of multiple private insurers, allows the affluent to buy better care, cannot reliably control costs, limits doctor choice unless you can pay more, and depends--for both financing and administration--on an employer or individual mandate.

What reformers must do, then, is make one last push for a single payer, single plan for the nation. This is hardly a lost cause: The Paul Wellstone-Jim McDermott bill has 92 co-sponsors in the House and five in the Senate, more than Jim Cooper's alternative, and California has put single payer on its November ballot. (But even Wellstone-McDermott relies on employer financing, which could cost jobs.) If single payer fails, we should intelligently draw lines in the sand to fight for what's essential. This means provisions that you can't be denied coverage; that you won't lose your insurance if you change jobs (called "portability"); that small businesses be able to ally with other businesses in order to gain bargaining power with insurers; and every American ought to have the right to buy the same plan that covers federal employees and members of Congress.

These are clearly doable reforms. More important but infinitely more contentious are universal coverage in the near future; cost control; comprehensive, equal benefits for every American; standardized paperwork and rules to determine...