Interview

Clinton’s New Deal for a healthier America

President Clinton’s health care reform programme
is gathering momentum, but faces powerful vested interests. Victor Sidel spoke to Steve Iliffe about the prospects for reform

The American health care system is expensive and socially unjust, yet reform has been resisted for decades. President Clinton wants to change all that - how far has he got?

Somewhere between 35 and 40 million people under retirement age in the US are not covered by health insurance, and rely on public services of variable accessibility and acceptability. The Medicaid programme, designed for the poor, now covers less than 40 per cent of those below the poverty line, compared with 66 per cent in 1980.

Another 20 million or so people are under-insured, so that a major illness can bankrupt them. Pensioners are covered by Medicare, but still pay over 50 per cent of medical expenses from their own pocket, which amounts to an average of one fifth of their income. Our health care system now uses up 13 per cent of our GNP, and looks set to reach 18 per cent by the end of the decade.

Clinton promised reform in his campaign, but the Task Force on National Health Care Reform headed by Hilary Clinton has only just produced its plans. She has struggled to bring together the vested interests that control US health care, and to mobilise public support and develop a plan that will avoid large tax increases.

‘Managed competition’ is the favoured approach, but the reception of the task force proposals by Congress and the many vested interests is likely to be hostile. We must expect heated debate but little action, with delays in implementing any new measures extending into 1994 and beyond.

Doesn’t Clinton need to win on health? It was a big issue in his election campaign, and the opinion polls consistently show the public wants change - perhaps radical change.

Opinion polls are not likely to change the political landscape significantly at the moment. The Clinton administration does need a successful outcome in health care, but Clinton’s team has made a number of errors, has no clear direction and is now under attack from both right and left for lack of focus and consistency.

The task force brought together a large number of health policy analysts from a wide range of executive and legislative offices and from a wide range of political backgrounds. Some activists on the left joined the task force because they thought there was scope for change, although they do not seem to have had much impact.

‘Managed competition’ - much like the UK’s ‘internal market’ - is the officially approved term, and some of the task force radicals see this as a step toward a ‘single payer’ system, equivalent to a national social insurance programme.

The task force set out to work in private and has suffered a stream of leaks as a consequence. It has been seen as excluding many with a legitimate interest in health care reform and has missed the chance to bring together many important interest groups and the educated public in an open debate about the future.

But vested interests are the problem rather than the solution, aren’t they?

Of course there are some extremely powerful interests, such as the insurance, drug and hospital industries - and organised medicine itself - which oppose fundamental reform of the health care system. Clinton’s apparent acceptance of the expertise of the Jackson Hole group of health policy analysts gives financial interests an enormous influence over his administration. The Jackson Hole group was from the outset little more than a gathering of insurance company executives, pharmaceutical industry leaders and luminaries from the American Medical Association. They have been very concerned to maintain a role for the insurance industry. No wonder the task force has been so interested in managed competition, even if the precedent for it - the health maintenance organisation - has been so uninspiring.

So how can these interests be overcome?

I am pessimistic about reform. The prospects for positive change are now minimal, I believe, and an opportunity has been missed. The right in the Senate and the House of Representatives has managed to stall Clinton’s economic proposals. The administration hopes these tactics will be punished in the 1994 congressional elections, when no doubt the task force proposals will be used as a weapon against the right. But the forces organised in favour of equitable access for the poor and powerless are relatively weak and disorganised, and recent by-election results are not encouraging.

Many of those who want change in health care have been convinced that their taxes are too high, despite the fact that the US has one of the lowest taxation levels in the Western world. They may oppose any proposals which threaten to raise their taxes even though private payments for health insurance would be reduced.

There is plenty of work to be done in educating the public about alternative forms of health care and their impact on access, quality and cost.