The Republican counterstrategy involves pursuing three distinct tasks: 1) deflating the exaggerated fears of systemic health care collapse that Democrats have encouraged; 2) clarifying and publicizing how the Clinton reform plan would alter and damage the quality and choice of medical treatment most Americans now take for granted; and 3) pointing out that incremental and meaningful solutions to problems of health security--solutions that do not require scrapping the current structure of American medicine and experimenting with something invented in Washington--are already available and politically within reach.
Deflating Fear. Genuine, yet remediable problems do exist in the American system of medicine, but the rhetoric surrounding the president's health plan deliberately makes those problems sound apocalyptic. "Fear itself" does not trouble the New Dealers: Indeed, they welcome it as a powerful tool of political persuasion. Mrs. Clinton, in particular, routinely describes a nation of individual lives teetering on the brink, each only an illness or a job away from financial ruin. The text of the president's Health Security Plan and virtually all the public remarks on health care made by his advisors are filled with images of a health care system spawning little else but frustration and tragedy. It is a brazen political strategy of fear-mongering, conducted on a scale not seen since the Chicken Little energy crisis speeches of President Carter.
Fanning the flames of public unease is a purely political tactic for the Democrats, and it deserves to be exposed as such. For while public concern about health care is undoubtedly real, the president's deliberate campaign of fright seems designed less as a response to the public and more as a justification for his own far-reaching, grand reforms. Republicans should scrupulously avoid endorsing the president's depiction of a nation beset by fear over health care, which provides him cover for the war-time, centrally-planned, emergency-style measures that characterize his alarmist overhaul of our medical system. Republicans should instead painstakingly debunk that account, and remind the nation, point by point, that it currently enjoys the finest, most comprehensive, and most generous system of medical care in world history.
Raising Questions About Medical Quality and Choice. The most devastating indictment of the president's proposal is that it threatens to destroy virtually everything about American health care that's worth preserving. Under the plan's layers of regulation and oversight, even seeing a doctor whenever you like will be no easy matter: access to physicians will be carefully regulated by gatekeepers; referrals to specialists will be strongly discouraged; second opinions will be almost unheard of; and the availability of new drugs will be limited.
So while there are now countless valid criticisms of the Clinton plan's various aspects, the most politically effective ones focus on how the proposal would fundamentally change the quality and kind of medical service that Americans cherish and expect. This mans an assault on the Clinton plan's two central tenets: mandatory, monopolistic health alliances and government price controls. Hand in hand, these two cornerstones of the president's plan will establish a system of rationed medical care.
Under Clinton's plan, the alliances will submit annual budgets to a national health board, thereby creating pressure to save money and trim service wherever possible. That means tightly regulated managed health care for most people, with an emphasis on efficiency over quality. Those who can afford huge premiums may be able to see a private fee-for-service doctor, though fee schedules will make it difficult for most independent physicians to stay in business. In time, the family doctor tradition will disappear. And avoiding this result by purchasing health insurance outside the alliances will be either impossible or criminal. The chief effect of price controls--the linchpin of the president's cost-containment theory--will be a rigid national system of pre-set budgets and medicine by accountants. There is no reason to believe that such a system won't follow the pattern that price controls have established in every other area: rationing, queueing, diminished innovation, black markets, and the creation of a government "health police" to enforce the rules.
Though the president and his surrogates deny all this, the basic building blocks of his proposal permit no other result. Republicans should insistently convey the message that mandatory health alliances and government price controls will destroy the character, quality, and inventiveness of American health care.
Advocating Security Without Upheaval. The initial appeal of the president's proposal is its promise of lifelong, universal security, defined in standard Democratic terms as a federal entitlement benefit. But this promise can also be restated as the plan's most glaring weakness: it mistakes federal spending and regulation for individual security. In exchange for his government-program security, Americans must accept a massive uprooting of the entire U.S. health care system, with disruptive and deleterious consequences.
As both a political and policy matter, the best counter-strategy to Clinton's offer of security requires resisting the temptation to compete with the president in a contest of radical reforms. Allaying public concerns about health security can be achieved by addressing a few basic problems directly--and without unraveling the current system. The easiest way to do that is by pursuing the short list of reforms for which there is already a national consensus. Relatively simple changes to insurance regulation, for example, can eliminate the barriers to health insurance for people with pre-existing medical conditions. The unemployed or people whose employers do not provide health insurance should be able to deduct the full cost of their premiums. The federal government could target its health spending to provide clinics in rural areas and inner cities where access to health care remains a problem. Long-overdue reforms to medical malpractice law would help lower insurance rates across the board. And a simplified, uniform insurance form would reduce paperwork, another unnecessary irritant of the current system. All these small steps would make health insurance less costly and health care easier to obtain.
Even where national health budgeting is concerned, there exist opportunities for significant reform that do not involve Great Society-style upheaval. States might be permitted to operate Medicare and Medicaid programs through managed care, for example, rather than through now-mandated fee-for-service plans--and thereby realize huge cost savings in their own budgets. (The Democratic governor of Tennessee recently applied for, and received, the necessary waiver of federal regulations to pursue just such a reform.) In fact, there are all sorts of cumbersome and costly health care mandates and regulations now imposed on states: they should be lifted to allow governors to allocate their federal programs in the most efficient way. The potential savings from Medicare and Medicaid--the engine of our escalating federal deficit--are enormous.
These are hardly revolutionary or even visionary proposals. In fact, variations of these reforms have been floating around the Congress for some time. Their simplicity and their lack of big-government "sophistication" stand in stark contrast to the extensive controls, reorganizing, standardization, and rationing that are at the heart of president's Health Security Plan.
IV. LAYING GROUNDWORK FOR THE FUTURE
These may only be intermediate measures. A more ambitious agenda of free-market reforms remains open for the future: medical IRAs, tax credits and vouchers for insurance, and the like. But Republicans must recognize the policy and tactical risks involved in near-term advocacy of sweeping change, however "right" it might be in principle. The Clinton plan's radicalism depends almost entirely for its success on persuading the nation that American medicine is so broken that it must not just be fixed, but replaced--wholesale and immediately. And it would be a pity if the advancement of otherwise-worthy Republican proposals gave unintended support to the Democrats' sky-is-falling rationale.
The more modest Republican reforms discussed earlier would have the virtue of cooling the feverish atmosphere--fostered largely and deliberately by the Administration--in which health care is currently discussed. And they offer a potentially might larger benefit to the Republican Party as a model of future conservative public policy: a practical vision of principled incrementalism. The character of Republican opposition to the president's health care plan, properly pursued, has broad implications. The party's goal, in health care and in other policy areas, should be to make the case for limited government while avoiding either simple-minded bean-counting, on the one hand, or Democrat-like utopian overreach on the other. The target of Republican policy prescriptions must be the individual citizen, not some abstract "system" in need of ham-fisted government repair. If we can, in this way, provide a principled alternative to the paternalistic experimentalism that consistently underlies Democratic ideas of governance, Republicans will be poised to claim the moral high ground in this and future debates.
The first step in that process must be the unqualified political defeat of the Clinton health care proposal. Its rejection by Congress and the public would be a monumental setback for the president; and an incontestable pice of evidence that Democratic welfare-state liberalism remains firmly in retreat. Subsequent replacement of the Clinton scheme by a set of ever-more ambitious, free-market initiatives would make the coming year's health policy debate a watershed in the resurgence of a newly bold and principled Republican politics.