Sickbed Populism
A mere six months ago, Big
Tobacco stood astride the American political scene, the colossus of evil. Every
public interest group despised it. Every Democratic politician railed against
it. Its public approval ratings trailed Linda Tripp's. Its political
contributions were tainted. But then something funny happened on the way to the
ballot box: Democrats found themselves a new boogeyman to replace the tobacco
barons. The Dems' new "merchants of death": health maintenance organization
bureaucrats.
The 1998
campaign's vilification of HMOs marks the culmination of a remarkable and
speedy collapse of the industry's image. Just five years ago, HMOs were the
golden children of the busted health-care industry, imposing the cost controls
and efficiencies everyone agreed the system needed. But during this summer and
fall, Democratic candidates have had a field day telling HMO horror stories.
HMO has become a synonym for heartlessness and windfall profit, and political
contributions by health insurers are blood money.
In the Missouri senate race, for example, a Democratic TV
ad declared that Republican incumbent Kit Bond would let "insurance company
bureaucrats make your medical decisions" because he had accepted $200,000 from
the insurance industry. An ad tarred Illinois' Republican gubernatorial
candidate George Ryan for accepting contributions from "exactly those HMOs that
are charging us more while providing us less." Arizona Democrat Paul Johnson
ran ads saying that incumbent Republican Gov. Jane Hull "has taken tens of
thousands of dollars from HMOs and big insurance companies and then steadfastly
refused to impose any meaningful reforms on an industry that is clearly out of
control." In North Carolina, Georgia, Wisconsin, Kentucky, Texas, Florida,
Ohio, and elsewhere, Democrats have anchored their campaigns to HMO reform and
depicted opponents as shills for the health insurance industry. The issue is
the key to "almost every race I'm involved in," says one Democratic
pollster.
As a
purely political matter, health insurance populism seems all upside for
Democrats. Americans always worry about health care, and they are especially
fretful about managed care. HMOs have new rules that they have not adjusted to
and don't much like, and the industry has its share of profiteering shysters.
HMOs are still an experiment: Americans have not yet decided if we like having
for-profit corporations controlling our medical care.
The pop culture, a leading political indicator,
is full of HMO bashing. Audiences at last year's movie As Good as It
Gets burst into applause at the line--voiced by the mother of a sick
child--"Fucking HMO bastards! Pieces of shit!" HMO horror stories have spread
widely and rapidly: "drive-through" baby deliveries, the experimental
chemotherapy denied to a child with cancer, the accountant who proposed
permitting cataract patients to have surgery on only one eye because you need
only one eye to see. (Consumers for Quality Care, an anti-HMO group, even picks
an HMO "Casualty of the Day.")
All this is fertile soil for
Democrats. Republicans in the Senate, after all, did just kill a
(relatively modest) HMO reform bill. Republicans are in the pockets of
the HMO and insurance industries. (Senate Majority Leader Trent Lott's office
told health insurance executives to "get off your wallets." And they did,
forking over millions to the GOP this election cycle.) And Democrats' proposed
reforms are not elaborate and not unreasonable: the right to sue your HMO, the
right to appeal denial of treatment, no gag rules for doctors, and easier
emergency room access. One survey showed that 90 percent of Americans support
such changes, and 85 percent would favor a candidate who supports them.
(Democratic HMO bashing is also an unexpected windfall from the defeat of
Clinton's 1993 health plan. Under the Clinton plan there would have been tacit
rationing, limits on service, and more rules about doctor visits--exactly the
kind of bureaucratization and handcuffing of doctors that Americans so deplore
in HMOs. Killing the plan has backfired on the GOP. Had Republicans let
Clinton's plan go forward, they would now be the ones campaigning against
bureaucratic medicine and telling nightmares about Clinton Care. Instead,
managed care went private, the Democrats get to inveigh against it, and the
Republicans are absorbing all the blame.)
Despite its political logic, this vilification of HMOs is a
dismaying manifestation of two common illnesses of American politics. The first
is Something-for-Nothingism. Democrats have seized the HMO issue this fall
because it is classic entitlement politics. Americans are understandably
ambivalent about health insurance. When your child gets sick, you naturally
despise the frugality that made your HMO so attractive when you subscribed.
Americans want--no, expect --health care to be both infinite and cheap.
We should have everything, paid for by someone else who shall remain nameless.
Democrats, by pushing regulation without acknowledging its costs, are feeding
this impossible expectation. (Something-for-Nothingism is, of course, the
guiding philosophy of almost all politics. There is no reason health care
should be an exception.)
A
principled Republican response to the Democratic anti-HMO campaign--and a
response that a few Republicans are actually making--is to say: "OK, if you
want to have the right to sue your HMO, you are going to have accept x
percent higher premiums and that's going to price y thousand customers
out of the health insurance market." But most Republicans, who are as willing
to pander as the next guy (heck, more willing), are afraid to fight on the
merits. Instead, they are countering one boogeyman with another, claiming that
voters should reject anti-HMO Dems because they are beholden to trial lawyers.
This is too bad, because a fight on the merits is exactly the way Americans
could make an informed decision about how much HMO regulation they want.
The anti-HMO strategy is also evidence of the
pernicious influence of Anecdotal Politics. The benefits of managed care are
unremarkable and undramatic (lower premiums, more preventive care). But its
costs are visible and awful (denial of and delays in care). The result:
Democratic candidates have terrible tales to tell, and Republicans have nothing
to reply with.
A 1997 Henry J. Kaiser
Family Foundation survey found that Americans in managed care plans are
basically content with their own care. But they are more worried about the
future than those in fee-for-service plans. Why? Largely because they have
heard so many alarming tales about HMOs. Never mind that no hard evidence
exists that American health care has actually deteriorated under managed
care.
This is why managed care is
a genuinely confusing issue: Should voters believe the anecdotes, which
are real and horrifying, or should they accept the evidence that people
are mostly happy with their own insurance, happy to be paying less, and as
healthy as they have ever been? Both parties in the '98 campaign offer an easy
answer to that question. The difficulty for voters is that neither answer is
completely right and neither is completely wrong.
