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A Bolt of Civic Hope

In an anti-political time the politics of remedy is still possible. Two congressmen, one liberal, one conservative, both versed in the relevant complexities, agree on the bones of a plan to insure the 44 million Americans without health insurance

by Matthew Miller

NAME a nettlesome social problem -- your favorite measure of cultural woe -- and chances are that today's record-long economic expansion has the statistics on it moving in the right direction. Violent crime, welfare rolls, child poverty, teen pregnancy, suicide, abortion, and divorce are all down. Jobs, SAT scores, air quality, the Dow, charitable giving, and even wages for less-skilled workers are all up. The trend lines are almost uniformly encouraging -- all except one.

The number of Americans without health insurance has soared during the current boom, from 37 million in 1993 (when Bill Clinton said it was a national problem requiring immediate attention) to 44 million today. Why? In part because so many of the jobs being created are at the low end of the labor market, where employers can't afford to offer health benefits or, if they do, employees can't afford to pick up their share, and in part because health-care costs -- after a brief respite in the mid-1990s, thanks to managed care -- are on the rise again, leading smaller firms to drop coverage. Experts say that the number of uninsured people could soon rise to 50 million if times remain good, and to 60 million or more if the economy dips.

Discuss this article in the Politics & Society conference of Post & Riposte.

More on politics and society in The Atlantic Monthly and Atlantic Unbound.

More on health in The Atlantic Monthly.

Web-only Sidebar:

"A Conversation With Jim McDermott and Jim McCrery"
The full transcript of Matthew Miller's conversation with the two congressmen.

From the archives:

"A Triumph of Misinformation," by James Fallows (January 1995)
Most of what everyone "knows" about the demise of health-care reform is probably wrong -- and, more important, so are the vague impressions people have of what was really in the Clinton plan.

"What Market Values Are Doing to Medicine," by Arnold S. Relman, M.D. (March 1992)
The former editor in chief of The New England Journal of Medicine fears that his profession has lost its ethical way.

"The Politics of American Health Care: What Is It Costing You?", by Godfrey Hodgson (October 1973)
"The health care crisis is upon us. In response to soaring costs, a jumbled patchwork of insurance programs, and critical problems in delivering medical care, some kind of national health insurance has seemed in recent years to be an idea whose time has finally come in America."

"The Medical Care Pork Barrel," by David D. Rutstein, M.D. (March 1961)
"Congress has clearly recognized that voluntary health insurance cannot meet the need, and financial assistance by the government for payment of medical bills for some of the aged is now a reality. But the present law also does not meet the need, and furthermore fosters direct local political control over the aged sick."

"The Health of the Nation: A Plea for Public Medicine," by Channing Frothingham, M.D.(February 1947)
"How shall we provide comprehensive high-quality medical care, including preventive medical procedures, early diagnosis, and treatment for all?"

From Atlantic Unbound:

Politics & Prose: "The Dissipation of Decency," by Jack Beatty (August 1998)
The real political scandal these days is the abandonment of those without health insurance.

Elsewhere on the Web
Links to related material on other Web sites.

The Bush Proposals
George W. Bush's position on health care, as described at his official campaign Web site.

The Gore Proposals
Al Gore's position on health care, as described at his official campaign Web site.

Issues 2000.org: George W. Bush on Health Care
An overview of Bush's stance on health care.

Issues 2000.org: Al Gore on Health Care
An overview of Gore's stance on health care.

Health Care on NPR
A collection of NPR's health-care coverage, in RealAudio.

What can the United States do about its medically uninsured?
The transcript of a seminar at the Columbia University Graduate School of Journalism. Speakers include: Chip Kahn (President, Health Insurance Association of America), George D. Lundberg, M.D. (Editor-in-Chief of Medscape), Thomas Reardon, M.D. (President, American Medical Association), Ron Pollack (Executive Director, Families USA Foundation).

"What Happened to Health Care Reform?", by Paul Starr
"The Republicans enjoyed a double triumph, killing reform and then watching jurors find the president guilty. It was the political equivalent of the perfect crime." An article in The American Prospect (Winter 1995).

Health Coverage 2000: Meeting the Challenge of the Uninsured
Information about a January, 2000, conference sponsored by Families USA, the Health Insurance Association of America, and the Robert Wood Johnson Foundation. The conference's goal was to "bring together many organizations with one common goal -- to make access to affordable health insurance a top national priority."

More than four in five uninsured Americans work year-round or live in families headed by someone who does. These waitresses, taxi drivers, and plumbers earn too much to be eligible for Medicaid but too little to buy coverage in the notoriously high-priced market for individual policies. They contract preventable diseases and are avoidably hospitalized more often than the insured, and are vulnerable to devastating financial loss from illness in ways unthinkable in other advanced nations. To be sure, some folks go without insurance only briefly, and a few who can afford it go without by choice (mainly people in their twenties who feel certain they'll live forever). But "the hard fact is this: the percentage of the population going without insurance involuntarily is growing year after year, in good times and bad," as one politician wrote his colleagues last year. "This is clearly a structural problem we ignore at our peril." The writer? House Majority Leader Richard Armey, of Texas.

Yet ignoring the problem of the uninsured is one of the few things that both Democrats and Republicans seem eager to do in the current presidential campaign. George W. Bush wants to offer tax subsidies of up to $2,000 per family to buy private insurance. But decent family policies cost more than twice that amount. And the roughly $10 billion a year Bush says he will devote to his plan means that his vaunted "compassion" will touch only a small fraction of the uninsured. This might not be surprising from a Republican candidate save for one striking fact: Bush's father in 1992 offered a version of the same plan that was considerably more generous -- $5,100 per family, adjusted for inflation, at a cost of $50 billion a year. And the father offered his generous plan when the federal budget deficit was nearly $300 billion; the son puts forth his token gesture at a time of comparably outsized surpluses.

Curiously, this shrinking of ambition when federal resources are finally available on a scale equal to the problem also characterizes the Democrats. Vice President Al Gore is offering a patchwork of coverage extensions, mainly for children -- who, because they incur fewer costly illnesses than adults, are a bargain to insure. His plans are a pale shadow of what the Administration was aiming for back when the problem was smaller.

Why are our leaders content to let the problem worsen while our means for addressing it have grown? The unflattering answer is because doing so is both safe and cheap. Today's uninsured are low-income workers with little political voice; in the broad-based recession of the early 1990s it was middle-class anxieties that had politicians scurrying to respond. A policy of rationing health coverage by income also saves money. The uninsured do get care in emergency rooms, county hospitals, and other sites of last resort. But these citizens consume just two thirds as much in health resources as their insured neighbors, because they don't get preventive care, regular checkups, and other services most people take for granted. We can fix the problem of the uninsured only by spending more money on people with little political clout -- and, if necessary, by somehow disguising that this is what we're up to.

Any such attempt, of course, will take place in the shadow of the Clinton health fiasco of 1993-1994. The political lesson both parties drew when Hillary Clinton's bulky plan was attacked unfairly as "socialized medicine" but quite fairly as too complex was that efforts to expand coverage must be incremental. "Step by step" is the approved mantra.

Yet incremental "achievements" since 1994 have been a bust. Senators Ted Kennedy and Nancy Kassebaum sponsored a bill passed in 1996 that was hailed by both parties as a model for future health reform. The measure was supposed to guarantee continued access to insurance for those who changed or lost their jobs. But insurers were free to charge whatever they liked in these situations, and people quickly found that "access" meant very little when a policy might cost $15,000 a year. Similarly, a plan costing $5 billion a year for the nation's 10 million uninsured children passed with great fanfare in 1997; aid was targeted so narrowly and complexly, however, that only one in five children it was meant to reach have been signed up. Bolder proposals, meanwhile, have proved easy to shoot down as unaffordable. Just ask Bill Bradley.

Indeed, in a year when a Democrat won his party's presidential nomination by attacking another Democrat for trying to insure all Americans, it is tempting to declare universal coverage a lost cause -- tempting but wrong. As it turns out, circumstances have quietly evolved in recent years in ways that leave both parties ready to make an ambitious push, together, on health coverage. This has taken place in a way scarcely visible in the Capitol's day-to-day political jockeying, but the parties, as they align, are poised to produce a movement of surprising power. Republicans, reeling from the failed "revolution" of Newt Gingrich and their associated image as uncaring thugs, have looked for ways to address the frustrations wrought by managed care. Many believe that giving voters more power to choose their health coverage will derail heavy-handed Democratic efforts to regulate private health care. At the same time, many liberal Democrats have come to terms with the fact that power in Congress will be roughly balanced between the parties for the foreseeable future. They've therefore become open to ways of expanding coverage that were once ideologically out of bounds. It sounds perverse, but some optimists say we're just one good recession away from seeing the political energy unleashed to solve this problem.

Luckily, we don't need a recession, because there's a pragmatic solution at hand that can command bipartisan support: tax subsidies for people who need help to buy insurance from competing private health plans. This is basically the scheme that President Bush offered in 1992 and that his son -- in embarrassing (but expandable) miniature -- offers today. It is the same general idea that Bill Bradley pushed earlier this year, and that policy analysts from shops as diverse as the Democratic Leadership Council and the conservative Heritage Foundation have been refining for a decade. A few bipartisan groups of legislators have put forth tiny versions of such a plan, but the time will be ripe after next month's election for the real thing. And although tax subsidies are not perfect (experts say, for example, that the poorest Americans will still need programs of direct aid and better-funded local clinics), and plenty of details remain to be thrashed out, this scheme offers the most realistic way of bringing the parties together to right an enduring wrong.

The story of the coming "grand bargain" on health care is one of Democrats accepting the existence of a private insurance industry and Republicans accepting the need to help make sure that everyone can buy a decent policy. It is a story of liberals agreeing that innovation shouldn't be regulated out of U.S. health care and conservatives agreeing that justice has to be regulated into it. It is a classic tale of mutual mistrust finally being trumped by mutual political advantage. I know this because after I had scoured Washington for months, talking with several dozen officials, health experts, and interest groups across the political spectrum in search of a workable way to get the parties together on this, an old-time single-payer liberal and a conservative Republican sat down with me and proved that the thing can be done.

The Politicians

THE moment Jim McCrery walked into Jim McDermott's office, near the Capitol, I felt relief. At least the meeting was going to happen. For two weeks we had been planning this session, yet every day I'd half expected one or both of them to call the whole thing off as unnecessary and strange. Why, after all, would a Republican and a Democrat, both of whom serve on the health subcommittee of the powerful House Ways and Means Committee, want to sit down for a journalist in an election year for a session resembling a negotiation? Politicians don't generally volunteer for press encounters they can't control. And as I had learned while making the rounds of Washington's health-policy gurus, getting a liberal and a conservative to discuss a pragmatic way to work toward universal coverage can get complicated.

It was an easy decision to seek out a duo in the House rather than in the Senate, because "the people's chamber" is ground zero for the partisanship that any consensus would have to transcend. The first pairing I thought of was Bill Thomas and Pete Stark -- the chairman and the ranking member, respectively, of the Ways and Means health subcommittee. But Thomas sees Stark as a hopeless liberal relic, and Stark sees Thomas as a heartless market fundamentalist. Thomas made it clear that he would participate in such a discussion only if paired with a centrist Democrat, such as Ben Cardin, of Maryland. But as I told Thomas, there was nothing interesting in the likelihood that he and a centrist Democrat could reach a deal. That happens every day. The question was whether a big-government liberal and a market-loving conservative could get together. If they could, maybe there'd be a chance for progress.

And so I turned to the Democrat Jim McDermott, of Seattle, and the Republican Jim McCrery, of Shreveport, Louisiana. McDermott, age sixty-three, went to Congress in 1988 after sixteen years in the state legislature. A psychiatrist by training, he is the longtime leader of the single-payer advocates in Congress, who wish to adopt a Canadian-style approach, under which the government doles out cash to regional health authorities that cover everyone and private insurance essentially doesn't exist. Since the Republican sweep of 1994, however, McDermott has stopped pushing this system. He even co-sponsored a Republican bill backing modest health tax credits in 1997.

McCrery, age fifty-one, is the Republican to watch on health care, according to several prominent Republican policy analysts. Also a member of Congress since 1988, he has studied the issue intensively in recent years, and argues that smart politics and sound policy require Republicans to shed their traditional view that health is not "their" issue. McCrery is among those being named as possible successors to Bill Archer, the retiring chairman of Ways and Means, in the scramble expected if the Republicans hold the House this fall.

McDermott scores 85 percent "liberal," McCrery 83 percent "conservative," on rankings compiled by National Journal, a Washington-based politics and policy magazine. They voted opposite ways on ten of twelve important votes tracked by that magazine in the past Congress. Personally, too, as I couldn't help noticing while they kibbitzed in McDermott's office, they're a study in contrasts. McDermott is a big man with a hearty laugh, whose boisterous energy seems better suited to the stump than to the Freudian couch. McCrery is slender and soft-spoken. He had to be asked to speak up for my tape recorder.

Staffers for both men had been pressing me for days for a write-up of the plan I had said I would offer as a point of departure for our talk. In the end, however, I decided that putting anything in writing was too risky -- it would be combed by staff members for unacceptable terms and could easily become a pretext for cancellation. Now, while a photographer posed McDermott and McCrery in unnaturally close positions, the two men, who plainly like each other, cracked uneasy jokes about what they had gotten themselves into. Finally they sat down -- McDermott on my left, of course, and McCrery on my right -- on a standard-issue government couch, beneath a wall of photos that included Mahatma Gandhi and a younger, dark-haired McDermott with Ted Kennedy. McDermott, smiling, said he appreciated the gesture his colleague had made by agreeing to meet in the office of the minority party. The tension soon eased, and they took off their jackets; in the event, they put off meetings and skipped a vote to extend an hour of planned conversation to nearly two.


(The online version of this article appears in three parts. Click here to go to part two or part three.)

Matthew Miller is a nationally syndicated columnist who is based in Los Angeles. He is a senior fellow at the Annenberg Public Policy Center of the University of Pennsylvania.

Copyright © 2000 by The Atlantic Monthly Company. All rights reserved.
The Atlantic Monthly; October 2000; Health Care: A Bolt of Civic Hope - 00.10; Volume 286, No. 4; page 77-87.