Rhetorical Malpractice

The health-care debate is obscuring the central issues.


Bill Clinton is lying about health care. If you've been awake for the last couple months, this news will not exactly come as a surprise. We're talking, after all, about a president who declares that his health-care plan has "no price controls" when it caps both insurance premiums and doctors' fees. He seems to assume, with reason, no one will actually read his health-care bill.

But prevarications of this sort aren't the big lie. The big lie, the lie that is making the health-care debate so vicious, isn't about details. It's about ideas. Here it is, as stated in the September draft of the health-care plan: "The values and principles that shape the new health care system reflect fundamental national beliefs about community, equality, justice and liberty. These convictions anchor health reform in shared moral traditions."

Nothing could be further from the truth. To the contrary, the debate over health care reveals deep moral divisions–differences about such fundamental political values as liberty and equality, diversity and control. But neither the White House nor most of its opponents will acknowledge or debate those differences.

Determined to maintain his "moderate" image, the president cannot defend a plan that is radically egalitarian, not merely guaranteeing a minimum level of health care for everyone but forbidding "a tiered system." He cannot explain why political decisions–about everything from premiums and copayments to what procedures are "necessary and appropriate"–are more valid than private contracts. He cannot justify centrally planning one-seventh of the economy. To defend his plan on its merits would mean revealing a profoundly un-moderate agenda. And that would be unpopular. So he lies.

Meanwhile, most Republicans aren't much better–and for similar reasons. With a few notable exceptions, such as Sen. Phil Gramm, they're convinced that ideas make bad politics. And they are conservatives, in the truest sense of the word. They defend the status quo, or some imagined version of it. Rather than support the evolving institutions created by choices in the marketplace, they've fixated on a particular form of health-care delivery–the unsupervised fee-for-service doctor. Like Clinton, they pick a health-care winner. Like Clinton, they attack the notion that health care is an economic good, one of many that enhance and extend life.

"For the health consumer in America, life under the Cooper plan would look very much as it would under the president's: standardized medicine, impersonal systems of care, and hospitals and doctors judged by economic efficiency standards," writes former Quayle aide Bill Kristol in a memo from the Project for the Republican Future. "'Cost containment' would become the mantra of American medicine … Doctors … would be required to report on procedures, treatments, outcomes, patient background, expenses and other 'necessary' medical information; health plans would withhold payment to any doctor who does not provide such requested data."

This scenario is one many Americans would not choose–given the alternative of infinite amounts of top-quality health care for free. But that isn't an option in the real world. When you pick apart Kristol's scare story, it simply says that doctors will be judged on their effectiveness, with enough data collected to yield statistically significant patterns that suggest what treatments actually work. Many private companies–both insurance providers and large employers concerned about benefit costs–are already requiring such information from doctors.

Attacking health-care management instead of government coercion leaves conservatives open to the charge that they're criticizing the system we already have. As Michael Kinsley writes in The New Republic, "Even without reform, market forces are already driving Americans by the millions … into managed care arrangements. 'Free market' style reforms being pushed by conservative Republicans will only speed this development." Kinsley's defenses of ClintonCare have, for the most part, been overwrought and misleading. But on this point, he's right. The problem isn't managed care; it's government controls.

In January, Republicans began suggeting that, contrary to the administration's assertions, we do not have a health-care "crisis." But most, notably Sen. Bob Dole, don't seem to know exactly why this argument is important, other than because Kristol told them to make it. So they've started to backtrack–to turn the question of "crisis" into mere semantics. We don't have a crisis, but we do have "serious problems," Dole says now.

The importance of the "crisis" issue lies in the hidden ideas of the health-care debate. In classical-liberal thought, emergencies–fires, floods, earthquakes–are like children; they justify government actions that wouldn't ordinarily be permitted. When the Northridge earthquake trapped people under a collapsed apartment building, no one thought the owners should be consulted before emergency crews ripped apart the structure to rescue survivors.

If there is a crisis, ripping apart the health-care system may be justified; if no crisis exists, such destruction is unwarranted–if, that is, you subscribe to the political ideas on which the country was founded. Even if you don't, you may worry that others do, which is why it's important both to create a sense of crisis and to hide the ideas behind the plans.

These hidden ideas matter a lot–not only to individual freedom but to medical progress. Thirty years ago, it was possible to envision a static medical system. So Medicare's proponents predicted that the program would cost only $12 billion by 1990, when in fact it cost $107 billion in constant dollars.

Since then, biology has become the most rapidly advancing science. It is either ignorant or malicious to slam centralized political controls on medical technology. Yet Clinton's plan and its cousins, including the "moderate" bill sponsored by Rep. Jim Cooper (D-Tenn.), would transfer decisions about what new procedures insurance can cover from the diversity of private companies, doctors, and hospitals to a single, politically appointed board. Uniformity will be the rule, every new idea a political issue. The White House assures us, "Guidelines that are developed by the Board will be developed in an open hearings process in which all interested parties can have input."

This process of turning over economic decision making to political officials is what Tom Hayden and Clinton's friend Derek Shearer dubbed "economic democracy," to make it sound better than socialism. It is a less honest form of expropriation than socialism, because it leaves ownership in private hands while vesting control in government. Thanks to "an open hearings process," landlords in Santa Monica still own their apartments but they cannot decide what to do with them. Hence the city's deteriorating housing stock. The same would be true of political medicine, with similar effects on quality.

The doublespeak of the health-care debate obscures the difference between private deals and government diktats. Thus we find Kinsley writing, "If a doctor contracts with the plan…" and "Forcing care providers to negotiate rates and then stick to them…"–as though contracts and negotiation mean the same thing when one party can dictate terms with the force of law. The National Health Board is not Kaiser Permanente or CIGNA or the Harvard Community Health Plan. It is the Justice Department and the IRS, the FBI and the Defense Department. It is the power of the state. Until the health-care debate acknowledges that fact, we can expect to hear a lot more lies.