Socialized Medicine, One Mandate at a Time


What the White House couldn't pull off in '94 with its five-pound Health Security Act, it's now threatening to do one piece at a time. President Clinton's goal: to ensure that managed care means "managed by government." Amazingly, some Republicans are helping him do it.

Three years ago, the proclaimed health crisis was "access," driven by spiraling insurance rates. The solution was "universal coverage" via a federally run system of managed care.

Today, after a period of stable prices, the crisis has become "quality." The solution: "minimum standards," code words for a federally regulated system of managed care.

A year ago, Clinton created the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry to prescribe how best to "promote and assure consumer protection and health-care quality." The commission, which will burn up more that $1 million in taxpayer dollars, delivered its first report, "The Consumer Bill of Rights and Responsibilities," last month.

Meanwhile on Capitol Hill, congressional Republicans, led by Sen. Alfonse D'Amato, R-N.Y., and Rep. Charles Norwood, R-Ga., are pushing the Patient Access to Responsible Care Act. So similar is the thinking at both ends of Pennsylvania Avenue that, upon the release of the commission's "Consumer Bill of Rights," Norwood chided Clinton for his dilatory approach.

"The time for talks and studies is over," Norwood said. "We already have the legislation that will correct the managed-care problems the presidential commission is finally addressing."

Both proposals claim to ensure a minimum level of quality, secured by federal mandates in such areas as choice of provider, access to emergency services and complaints and appeals. One theme is constant: It's dangerous for markets to evolve without the express written consent of the federal government.

The problem is not a lack of safeguards for consumers; it's that these standards are emerging from the managed-care marketplace and haven't been dictated by Washington.

Consider the push for "network adequacy." Both the commission and the congressmen want the federal government to mandate network standards—that is, to dictate staffing levels to managed-care companies. That consumers and corporate benefit buyers might be able to appraise the quality of a network against the price of the product on their own seems not to occur to the Washington players.

The same mentality is center stage in the chapter on complaints and appeals in the "Bill of Rights." The commission notes that "(v)irtually all private and public health plans provide consumers with some form of complaint resolution process." But, it complains, these standards are neither uniform nor backed by the federal government. The proposed solution? A mandatory external review board.

Then there is the wild card. PARCA states: "No insurance issuer may discriminate . . . in any activity that has the effect of discriminating against an individual on the basis of race, national origin, gender, language, socioeconomic status, age, disability, health status or anticipated need for health services." The commission's recommendations contain similar language.

This could be a Trojan horse for two policies that would destroy the market for private health insurance: guaranteed issue—if a plan is open to one it must be open to all—and community-rating of premiums—old and young, sick and healthy, all pay the same premiums.

Upon accepting his commission's recommendations, President Clinton's remarked, "While people may not have wanted to bite the whole apple at once in 1994, almost the whole populace wants to keep nibbling away at the apple."

The forces of socialized medicine are back. Their target may be managed care, but their goal is national health care, one mandate at a time.