Control Freaks

Virginia Postrel from the December 1993 issue

Thanks to the profit-seeking souls at Times Books, you don’t have to be a lobbyist or congressional aide to get your hands on the text of the Clinton health-care plan. You can go to the mall and pick up a 284-page paperback copy for $8. But judging from the way both supporters and opponents are describing it, even the pros haven’t really read the plan.

When supporters talk about it, they sound like cheery personnel officers guiding new employees through company benefits packages. "We offer two choices of plans," they say. "There’s the fee-for-service plan, where you have a $200 deductible, and the preferred provider network, where you pay only $10 a visit. Which would you like to sign up for? We recommend the cheaper one."

Opponents, on the other hand, make the Clinton plan sound like just another expensive entitlement scheme: Aid for Families with Dependent Sick People. They warn of heavy payroll taxes–if you like FICA, you’ll love Clintoncare–and runaway costs. They talk about the deficit and lost jobs.

Both sides treat the health-care plan as the latest lavish program for taxing and spending. One side emphasizes the benefits, the other the costs. Neither gets to the real story.

Despite the neat charts you’ve probably seen reprinted in your local newspaper, most of those 284 pages have nothing to do with describing benefits. And very few talk about paying for them.

The Clinton plan isn’t a simple transfer scheme. It is a systematic program for destroying the health-care industry and replacing it with regional cartels, government price caps, and mass, standardized medicine. It is not about handouts or subsidies, though it includes both. It is about unbridled, unaccountable bureaucratic rule.

Sure, the plan has its silly and expensive moments. It suggests covering aerobics ("physical training classes") in the name of preventive care. It picks up everyone’s therapist bills, promising a cost explosion unmatched since California started allowing worker’s comp claims for "stress."

At its most absurd, the Clinton outline declares that "health plans may not terminate, restrict or limit coverage for the comprehensive benefit package for any reason, including non-payment of premiums." (Emphasis added.) It’s easy to see where that will lead. Why pay when you can get the same care for free?

But the heart of the plan is not expensive indulgences. It is, rather, an attack on choice and competition. In page after mind-numbing page of bureaucratic detail, the plan closes every conceivable avenue of escape, plugs every possible source of diversity, eliminates every incentive for innovation. It threatens new drugs with price controls, forbids hospitals and universities to train more than a constricted number of specialists, requires urban health plans to serve rural areas, and makes paying extra for care a crime.

To read the plan carefully, to picture the world it describes in deliberately abstract language, is to begin to see the forest amid the trees. And it is The Forest of No Return. Those who stumble in never can get out. Bill Clinton is nationalizing the health-care industry and doesn’t have the guts to admit it.

The centerpiece of the plan is the system of "regional health alliances." An alliance may be a state agency or a nonprofit corporation overseen by your state. The government-appointed alliance board determines which companies can offer hearth plans in your area. Employers and self-employed people pay premiums to the local alliance, and "it is the obligation of every eligible individual to enroll in a health plan."

The regional alliance resembles the local cable franchise–a governmentcreated monopoly through which consumer services flow. "States may establish one, and only one, regional alliance in each area."

Like a cable company’s, the alliance’s prices and services are tightly regulated. Consumers have "choice" among health plans offered through the alliance, just as they can choose whether to buy Showtime or HBO from the local cable monopoly. But the number of plans is limited, and most are nearly identical. (The plan lets big companies establish their own "corporate alliances" for employees, but it doesn’t let them offerplans that pay higher fees than the standard government ones.) Consumers are stuck with a single regional alliance that has no competition and thus no incentive to give good service. The only escape is to move to another region and hope the new alliance is better.

Each plan must provide a standard benefit package and price its premiums within a narrow range based on a "target" established by a National Health Board. If premiums are too high, they have to be "renegotiated" or reduced via an "assessment" (a.k.a. a tax) on high-priced plans. The Clinton outline doesn’t specify what happens if no company will sell its services at the approved premium. But it does give each state the option of establishing a government-run single-payer plan. In other words, it provides a mechanism for establishing a Canadian-style socialist system through the back door, without the messiness of a congressional vote.

Much of the plan deals with various sorts of price controls. Bill Clinton is obsessed with containing the cost of health care–he brought it up incessantly at the Little Rock economic summit. But the Clinton plan eschews any thought of making consumers more sensitive to prices. It deliberately limits out-ofpocket costs "to ensure financial protection" even as it expands "free" care not only to the now uninsured but also to people whose current insurance plan is less lavish than the "guaranteed benefits package."