BOSTON BRIEFING * BRIEFING DE BOSTON
issues given short Health care issues given short
Health care shrift in
US
election campaigns
Charlotte Gray
Charlotte Gray's Capital Accounts column, which has served as a forum for the discussion of Canadian political and health care issues since May 1987, will be taking a year's leave of absence from the pages of CMAJ. Gray is spending the next year in Boston, and for that period her new column, Boston Briefing, will focus on health care issues south of the border. S omewhere around mid-September, the US presidential election campaign turned into a dogfight. Of course, the candidates carried on repeating their slogans. George Bush insisted that the American economy was turning the corner. Bill Clinton, the Democrat, declared that it was time for change. Ross Perot, the independent, ripped into "Washington lawyers in alligator shoes" who didn't realize, or care, what was going on in the rest of the country. In the presidential debates, the usual policy buttons were pushed: abortion, taxes, defence, law and order, and health care. But by the time the November election loomed, it was hard to find much substance in any of the campaigns: the fight for the White House had become an intensely Charlotte Gray, a CMAJ contributing editor, is spending a year in Boston. NOVEMBER 15, 1992
personal slanging match, and phrases such as health care reform were simply truncheons that could be used to whack another candidate on the head. Why discuss policy when you can shout accusations about avoiding an unpopular military draft more than 20 years ago?
Larry King, the Cable News Network's reigning chat champ, says that there is a difference between the way callers to his show talk to presidential candidates and to convicted felons. "They're much more polite to the felons," he explains. "People have gotten so direct and angry in dealing with politicians that once you're running, you're public meat." Whatever the reason, the candidates' campaigns appeared both mean and trivial to a Canadian I realize that the occupant of eye. "You can tell that the Oval Office must be tough, Clinton has already but does he really need to comdecided that he's going bine the slick manners of a gameto offend the insurance show contestant with the go-forthe-jugular instincts of a streetindustry." fighting thug? This article was written beWilliam Hsiao, fore the result of the Nov. 3 vote was known. However, a Clinton Harvard School of victory was widely predicted dePublic Health spite Bush's attempt to nail his opponent for, as Clinton put it, "a draft I didn't dodge and a woman I never slept with." During the campaign, Clinton appeared to have done the most Why things happen this way thinking about how to tackle longis anybody's guess. Perhaps it is overdue health care reform in the the nature of presidential politics, US. So, on the bold assumption which has always been more that January will see the inauguragladiatorial than Canada's parlia- tion of this new Democratic presimentary processes. Perhaps it is dent, it is interesting to see where because, for the first time, candi- Clinton wants to head with health dates have appeared more often care. on television talk shows than news Clinton has backed a univershows. sal health insurance plan since the CAN MED ASSOC J 1992; 147 (10)
1551
start of his campaign. He is determined to ensure coverage for the more than 30 million Americans who have no health insurance, and the millions more who have inadequate coverage. Stripped of rhetoric, the Clinton plan comprises three measures. First, he advocates a global budget for health care expenses, in order to control costs. Second, he calls for price controls on doctors, hospitals and health maintenance organizations. Third, he wants to initiate a "play or pay" strategy: employers either offer health insurance to their employees, or they pay into a public program that will cover the employees. Individual contributions to this publicly sponsored plan, which will also cover the unemployed, will be based on income. "We've got to quit having the federal government try to micromanage health care, and instead set up incentives for the private sector to manage costs down within limits beyond which we absolutely must not go," Clinton explained in a campaign speech to employees of a pharmaceutical firm in September. His plan includes rigorous cost controls on prescription drugs and medical procedures, would encourage competition among insurance companies, and is intended to guarantee access to health care. At the same time, Clinton wants more preventive care, and promises to promote health maintenance organizations as competitors to fee-for-service doctors. He is also anxious to introduce a system of "smart cards" as a streamlined, way to handle billing procedures. Without doubt, there are enormous savings to be made in the US system, which right now constitutes an $800-billion (US) market that is almost as large as the entire British economy. Many think that much of the $800 billion is wasted - "Experts agree 25 percent of surgery and tests 1552
CAN MED ASSOC J 1992; 147 (10)
unnecessary" was the headline planners to face the same difficult over a recent Wall Street Journal questions their Canadian counterparts have dealt with for years. article. Money-saving strategies are Bush revealed his discomfort with only half the answer to the dilem- the arguments when he dismissed ma facing the new president. De- his opponent's policies as "socialspite vague assurances from Clin- istic." If health care issues failed to ton advisers, anticipated savings will not be enough to fund insur- dominate the presidential elecance coverage for the millions of tion, they failed to break the surAmericans who need it. Nor are face in the congressional election the cost controls likely to provide campaigns, even though opinion enough incentive to persuade pa- polling showed US voters in a tients to use health maintenance mood to approve radical reform organizations instead of fee-for- action. Maryann O'Sullivan, execuservice doctors. tive director of Health Access Foundation, a San Francisco lobby group, told one newspaper that the $60 million (US) in contributions that congressional candidates have received from health care and drug firms and insurance "We've got to quit carriers might have had somehaving the federal thing to do with the relative sigovernment try to lence. micromanage health The reluctance of American to get involved in an politicians care.'" intense health care debate might suggest that, despite Clinton's best - Bill Clinton intentions, he may choose to duck the issues if and when he is elected. But that's not likely, says William Hsiao, a professor of health systems economics at Harvard University's School of Public Health. Hsiao points out that there Clinton shied away from proposing to use the tax system to are six powerful organized groups drive consumers into managed in the US that play major roles in care. Such a step may be obvious shaping health care policy: physito a Canadian health care planner, cians, hospitals, the insurance inbut it is anathema to Americans, dustry, business, labour and the elderly. Business, labour and the who consider "tax" a dirty word. I are leaning toward basic debate, US elderly As I watch the realize that American politicians reform: organized medicine, hoshave hardly begun to define their pitals and the insurance industry terms on issues such as the profes- are fighting for some variation on sional independence of physi- the status quo. "You can tell that Clinton has cians, the ability of government to regulate a highly technical and already decided that he's going to rapidly changing field, and the offend the insurance industry," inadequacies of marketplace eco- says Hsiao. "That signals to me nomics as a model for distributing that he is going to take on health care reform. Otherwise, there is health care resources. Trying to put a limit on the no reason for him to alienate a spiralling costs forces American very powerful group of people."For
prescribing information see page 1605
-
issues given short Health care issues given short
Health care shrift in
US
election campaigns
Charlotte Gray
Charlotte Gray's Capital Accounts column, which has served as a forum for the discussion of Canadian political and health care issues since May 1987, will be taking a year's leave of absence from the pages of CMAJ. Gray is spending the next year in Boston, and for that period her new column, Boston Briefing, will focus on health care issues south of the border. S omewhere around mid-September, the US presidential election campaign turned into a dogfight. Of course, the candidates carried on repeating their slogans. George Bush insisted that the American economy was turning the corner. Bill Clinton, the Democrat, declared that it was time for change. Ross Perot, the independent, ripped into "Washington lawyers in alligator shoes" who didn't realize, or care, what was going on in the rest of the country. In the presidential debates, the usual policy buttons were pushed: abortion, taxes, defence, law and order, and health care. But by the time the November election loomed, it was hard to find much substance in any of the campaigns: the fight for the White House had become an intensely Charlotte Gray, a CMAJ contributing editor, is spending a year in Boston. NOVEMBER 15, 1992
personal slanging match, and phrases such as health care reform were simply truncheons that could be used to whack another candidate on the head. Why discuss policy when you can shout accusations about avoiding an unpopular military draft more than 20 years ago?
Larry King, the Cable News Network's reigning chat champ, says that there is a difference between the way callers to his show talk to presidential candidates and to convicted felons. "They're much more polite to the felons," he explains. "People have gotten so direct and angry in dealing with politicians that once you're running, you're public meat." Whatever the reason, the candidates' campaigns appeared both mean and trivial to a Canadian I realize that the occupant of eye. "You can tell that the Oval Office must be tough, Clinton has already but does he really need to comdecided that he's going bine the slick manners of a gameto offend the insurance show contestant with the go-forthe-jugular instincts of a streetindustry." fighting thug? This article was written beWilliam Hsiao, fore the result of the Nov. 3 vote was known. However, a Clinton Harvard School of victory was widely predicted dePublic Health spite Bush's attempt to nail his opponent for, as Clinton put it, "a draft I didn't dodge and a woman I never slept with." During the campaign, Clinton appeared to have done the most Why things happen this way thinking about how to tackle longis anybody's guess. Perhaps it is overdue health care reform in the the nature of presidential politics, US. So, on the bold assumption which has always been more that January will see the inauguragladiatorial than Canada's parlia- tion of this new Democratic presimentary processes. Perhaps it is dent, it is interesting to see where because, for the first time, candi- Clinton wants to head with health dates have appeared more often care. on television talk shows than news Clinton has backed a univershows. sal health insurance plan since the CAN MED ASSOC J 1992; 147 (10)
1551
start of his campaign. He is determined to ensure coverage for the more than 30 million Americans who have no health insurance, and the millions more who have inadequate coverage. Stripped of rhetoric, the Clinton plan comprises three measures. First, he advocates a global budget for health care expenses, in order to control costs. Second, he calls for price controls on doctors, hospitals and health maintenance organizations. Third, he wants to initiate a "play or pay" strategy: employers either offer health insurance to their employees, or they pay into a public program that will cover the employees. Individual contributions to this publicly sponsored plan, which will also cover the unemployed, will be based on income. "We've got to quit having the federal government try to micromanage health care, and instead set up incentives for the private sector to manage costs down within limits beyond which we absolutely must not go," Clinton explained in a campaign speech to employees of a pharmaceutical firm in September. His plan includes rigorous cost controls on prescription drugs and medical procedures, would encourage competition among insurance companies, and is intended to guarantee access to health care. At the same time, Clinton wants more preventive care, and promises to promote health maintenance organizations as competitors to fee-for-service doctors. He is also anxious to introduce a system of "smart cards" as a streamlined, way to handle billing procedures. Without doubt, there are enormous savings to be made in the US system, which right now constitutes an $800-billion (US) market that is almost as large as the entire British economy. Many think that much of the $800 billion is wasted - "Experts agree 25 percent of surgery and tests 1552
CAN MED ASSOC J 1992; 147 (10)
unnecessary" was the headline planners to face the same difficult over a recent Wall Street Journal questions their Canadian counterparts have dealt with for years. article. Money-saving strategies are Bush revealed his discomfort with only half the answer to the dilem- the arguments when he dismissed ma facing the new president. De- his opponent's policies as "socialspite vague assurances from Clin- istic." If health care issues failed to ton advisers, anticipated savings will not be enough to fund insur- dominate the presidential elecance coverage for the millions of tion, they failed to break the surAmericans who need it. Nor are face in the congressional election the cost controls likely to provide campaigns, even though opinion enough incentive to persuade pa- polling showed US voters in a tients to use health maintenance mood to approve radical reform organizations instead of fee-for- action. Maryann O'Sullivan, execuservice doctors. tive director of Health Access Foundation, a San Francisco lobby group, told one newspaper that the $60 million (US) in contributions that congressional candidates have received from health care and drug firms and insurance "We've got to quit carriers might have had somehaving the federal thing to do with the relative sigovernment try to lence. micromanage health The reluctance of American to get involved in an politicians care.'" intense health care debate might suggest that, despite Clinton's best - Bill Clinton intentions, he may choose to duck the issues if and when he is elected. But that's not likely, says William Hsiao, a professor of health systems economics at Harvard University's School of Public Health. Hsiao points out that there Clinton shied away from proposing to use the tax system to are six powerful organized groups drive consumers into managed in the US that play major roles in care. Such a step may be obvious shaping health care policy: physito a Canadian health care planner, cians, hospitals, the insurance inbut it is anathema to Americans, dustry, business, labour and the elderly. Business, labour and the who consider "tax" a dirty word. I are leaning toward basic debate, US elderly As I watch the realize that American politicians reform: organized medicine, hoshave hardly begun to define their pitals and the insurance industry terms on issues such as the profes- are fighting for some variation on sional independence of physi- the status quo. "You can tell that Clinton has cians, the ability of government to regulate a highly technical and already decided that he's going to rapidly changing field, and the offend the insurance industry," inadequacies of marketplace eco- says Hsiao. "That signals to me nomics as a model for distributing that he is going to take on health care reform. Otherwise, there is health care resources. Trying to put a limit on the no reason for him to alienate a spiralling costs forces American very powerful group of people."For
prescribing information see page 1605
-
