Rethinking the Welfare State: The prospects for ... - e-Library

Rethinking the selfare state 6
Force on Health Care Reform, chaired by Hillary Clinton. In a few months, the Task
Force had drafted the HSA, a massive bill of some 1,500 pages. The HSA would provide
universal coverage for all Americans not already privately insured, employer mandates
requiring employers to provide coverage to their employees, and allow for the formation
of alliances under which groups of companies could purchase policies collectively, thus
ostensibly reaping bulk discounts. 31 Whilst allowing alliances and individual employers
their choice of insurers, the HSA also stipulated certain minimum comprehensive
coverage standards in the form of a “benefits package,” including (among many other
items) “hospital services, services of health professionals, emergency and ambulatory
medical and surgical services, clinical preventive services, mental health and substance
abuse services.” 32 The HSA provided flexibility for state governments and employers,
including the option (for states) of going to a single-payer system, and (for corporations)
of forming alliances with other bulk insurance purchasers. It also represented a (highly
regimented) tied demand-side subsidy scheme, assuring low-income Americans the same
choice of health care providers available to all other insured persons—albeit not the same
choice of insurers. 33
Despite the fact that the program would have provided health care coverage for all
Americans not having health care insurance, the program was uniformly opposed by
Republicans and even by many conservative and liberal members of the President’s
Democratic party. 34 The acrimonious and divisive debate over the HSA in Congress was
mirrored by a similarly heated debate in public fora. The Health Insurance Association of
America, concerned about the increased liability they would face due to restrictions on
refusing high-risk clients and the costly comprehensive minimum coverage rules,
unleashed a multi-million dollar television advertising campaign condemning the bill, a
campaign that stretched on for nearly 10 months. 35 Physicians, largely alienated from the
HSA drafting process and concerned about the delegation of health-related decisionmaking
powers “from MDs to MBAs,” 36 also opposed the bill. 37 The US Chamber of
Commerce, the National Association of Manufacturers and the National Federation of
Independent Business, and a Business Roundtable of some 300 businesses of various
sizes, all concerned about the costs of the employer mandate portion of the HSA, directed
their support, and their lobbying resources, behind a much more modest initiative. 38 As a
consequence of these efforts, as well as of the war of rhetoric accompanying the bevy of
competing alternative bills, public interest in health care reform gradually eroded and
gave way to cynicism and confusion. 39 By the spring of 1994, only 12 percent of
Americans expected to see a net gain for themselves under reform “through some
combination of lower costs and increased quality of care.” 40
Although there is little doubt that the HSA suffered from critical design problems,
including, ironically, a tendency for excessively centralized decision-making and
planning, nevertheless, the role played by vested interests, ranging from physicians’
groups to business lobbies, in scuppering the HSA and its voucher-based initiatives
should not be underestimated. As one commentator noted, the single most intractable
obstacle to health care reform was the limited political support for a program perceived to
be inherently redistributive, i.e. predicated on moving resources from higher wealth
quintiles to lower. 41