The Blog


11:00 PM, Jan 12, 1997 • By DAVID FRUM
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In President Clinton's first term, the Democrats had a vision: a sudden and dramatic takeover of the nation's health-care system that would upend the nation's economy and transform its politics. The plan was candidly megalomaniacal, grandiose, and preposterous. Unsurprisingly, the Democrats were clobbered.

Now, for Clinton's second term, the Democrats again have a vision: a series of opportunistic little interventions, each of which can be described as " modest" and "incremental," that will over time prepare the way for . . . a sudden and dramatic takeover of the nation's health-care system. This time nobody can credit them with candor.

We already have a law mandating a 48-hour hospital stay for new mothers; soon we will have a law mandating a 48-hour stay for women recovering from mastectomies. President Clinton favors a law to compel health-maintenance organizations to describe to subscribers the most expensive possible treatments for their ailments. He wants to oblige employers to maintain the health insurance of workers even after they are fired, and he wants the federal government to ensure health-insurance coverage for everyone under the age of 19, as well as all new mothers.

Unlike the 1993 plan, the president's health-care proposals do not add up to a coherent (if cuckoo) whole. Instead, they represent a series of calculated attacks on what remains of private markets for health insurance, and their effect will be to make private health insurance even more expensive and difficult to obtain.

It may be that the proponents of these suggestions do not mind that outcome. They may believe that the health-care village must be burned down if we are to save it. The more costly and inaccessible they can make private health insurance, the more quickly they can rebuild a constituency for . . . a sudden and dramatic takeover of the nation's health-care system.

But whatever the intentions of the proponents of these incremental steps in the wrong direction, Republicans need to be wary. Consciously or not, health- care reformers are pushing America toward a marketplace in which private insurance becomes increasingly unaffordable and more and more Americans depend on government to finance their medical needs. In a future like that, government spending will rise uncontrollably, valuable innovation will be stifled, and quality of care will inevitably deteriorate.

Unfortunately, Republicans are failing to muster sufficient resistance to this grim outcome. If the private market is to be given a fair opportunity to show what it can do to deliver high-quality medicine to all, Republicans will need to think their way to an understanding of health-care reform radically different from that favored by the president and the congressional Democrats. The problem with Bill Clinton's 1993 plan was not that it went too fast, but that it went in entirely the wrong direction. Moving "incrementally" in the wrong direction may be an improvement over rushing to perdition; but it isn't a very big one.

Nobody would deny that America's health-care system suffers serious and seemingly intractable problems. The worst of these problems is that at any given moment some 30 million Americans, including almost 6 million children under the age of 11, have been uninsured for a year or more. These people are not the very poor; the very poor are covered by Medicaid. Typically they are low-wage earners whose employers will not buy insurance for them and who cannot afford to buy it for themselves. Should they get very sick -- should they be hit by a car or suffer a stroke -- they will probably find an emergency room to care for them and hide the expense in the bills of the paying patients. But when it comes to more routine care, and especially preventive care for themselves and their children, they too often go without.

What these folks need is an inexpensive, uncomplicated health-insurance policy that will cover basic needs at a reasonable price. Right now, health insurance for a family or a membership in an HMO begins at $ 3,000 a year, a ruinous price for a worker bringing home, say, $ 18,000 in wages.

Bizarrely, virtually every idea that goes under the rubric of "health-care reform" would raise those prices even higher. Suppose America's working poor were having terrible difficulty affording clothes. It would hardly make sense to pass a law compelling them to shop only at Neiman Marcus or Saks Fifth Avenue. Suppose car prices were rising fast. Who would propose outlawing the sale of used cars? But that, essentially, is what the president's " incremental reforms" do.