Experts Express Concern Over Clinton Health Plan

Just five months after President Clinton's first self-imposed deadline for a health care plan passed, doctors, consumers, and medical students are all busy scratching their heads as they try to understand the plan, unveiled to the American public Wednesday night.

Beset with the reality of an expensive health care system that fails to cover 37 million Americans, experts at Harvard and elsewhere are looking to Clinton's plan with a glint of hope--but also a sea of worries.

The plan, which seeks to limit a family's out-of-pocket medical expenses to $3,000 a year, received mixed reviews from all corners of the health care community. Some experts, citing Clinton's vigorous call to arms, were enthusiastic that his spirit would prevail and allow some form of the plan to pass through Congress.

But others questioned various aspects of the proposal, from important details Clinton omitted, to outright doubt that the plan would help those who most need it.

Clinton's long-awaited proposal, ready in some states by 1995, would have workers in a given area pay equal rates for equal coverage. Workers would keep their insurance if they lost a job or changed jobs.

But it appears that many citizens will be forced to give up the precious right of choosing their doctors, or at least pay more for that privilege.

And some experts, while supporting theunderlying themes and message of the plan, saythere are more problems. For example, says Dr.Daniel D. Federman, dean for medical education atHarvard Medical School, the quality of care maynot be sufficiently championed in thenegotiations.

"I would like to see an explicit address topreserving quality and preserving education, andI'm concerned they are less well spoken for in thepresent design than universality, simplificationof paperwork, et cetera," he says.

And on the physicians' side, says one currentMedical School student, Clinton's plan may alsopose special potential problems for medicalstudents, including the freedom to choose theirarea of specialization.

Steve N. Kalkanis `93, a first-year MedicalSchool student, says the plan might require acertain number of graduates to become familypractitioners, thereby limiting the number ofresidencies in specialties. The cause for primarycare has been championed for several years, andsome organizations have called for a quota formedical school graduating classes of 50 percentprimary care physicians.

"As a med student, I'm still guarded and prettyskeptical," says Kalkanis.

But Kalkanis said he was comforted by Clinton'sreassurance that doctors were not the problem withthe health care system. "I'm somewhat relieved hemade an effort to emphasize that doctors weresomething good that should stay. He sent out amessage that he's not out to hurt the physiciansand the medical profession," he says.

Federman, who says he supports the underlyingprinciples of the plan, said he could not predict,as dean of medical education, what effectClinton's reforms would have on medical schools.

"Enrollment in medical school for six years hasbeen a growth industry, and the figures havealready surpassed those of last year," saidFederman. "What it will do in two years, smartdoctors don't predict."

Federman says he supports the plan's attempt tobreak the link between insurance and employmentstatus, its effort to control costs and especiallyits coverage of medication and long-term care forthe elderly.

He says the uninsured and the working lowermiddle class, whose coverage are often inadequate,would gain most from the plan. "The elderly willgain if prescription coverage is retained," hesays, "and those with job related insurance willgain because they will be free to carry insurancewherever they go."

Federman emphasizes the importance ofpreserving preventative medicine in the plan,citing the country's "very bad record inimmunization."

The dean is concerned that two of the plan'skey aspects remain uncertain: the costprojections, including the tax impact, and theapproach to managed competition.

Federman says he is unsure whether managedcompetition, which has never been tried, would beas promising as proponents hope. "The plan isterrific on access, very hard to interpret forcosts, and not explicit about quality," he says.

O Canada?

Criticisms by other public health experts,however, went more to the basic tenets of theproposal, such as its heavy reliance on employersto provide benefits.

Peter Hiam, former commissioner of insurance ofMassachusetts and now a professor at the BostonUniversity School of Public Health, said heopposes Clinton's employment-based system.

According to Hiam, it was a historical accidentthat employers provide insurance. During World WarII, there were price controls and employers gaveout health benefits. Ever since, employers havesimply continued to provide benefits.

Hiam is opposed to the employment-based systembecause it requires that each employer have anindividual insurance company, creating a "needlesscomplication."

"The system we have is a nightmare [because itis so] complex," says Hiam. "I'm not belittlingthe potential for improvement. What's a shame isthat [Clinton's] not being so bold to simplify andmake the system more fair."

But more specifically, Dr. Ezekiel J. Emanuel,assistant professor of medicine and of socialmedicine at Harvard Medical School, says hedoubted a simplified form for patients wouldimprove quality.

"Everyone who knows anything about improvingquality knows you will have to have more forms,[not fewer], in assessing patient outcomes," hesays.

Hiam says he thinks Clinton endorses anemployment based system because of state politics:it is the easiest method by which to please asmany people as possible, he says.

And Rashi Fein, professor of economics ofmedicine at the Medical School, while callingClinton's speech an excellent "call to arms," saysa single payer system, similar to Canada's, wouldhave been a better choice. Universal insurancewould not be paid by employers, but by abroad-based tax based on ability to pay, in aversion of Canada's much-touted health caresystem.

"Think of it as free public education. Everyonegets it, but we don't base it on who you workfor," he says. "The plan would have been simpler,and we wouldn't have had to compress evolutionarychanges into a revolutionary time period."

Fein also says that the plan's financing,largely based on expected savings, would not comequickly enough. "Clinton will be under pressure tolet the deadline slip a bit."

Calling The Odds

What remains unclear is the plan's chances forpassing the difficult hurdle of Congress. Dr.David Blumenthal '70, chief of health policyresearch and development at the MassachusettsGeneral Hospital, says the commitment to universalhealth care, cost containment, and the opportunityfor physician choice are essential for the plan'spassage in Congress.

Like other experts, Blumenthal, who was one of47 non-government health policy experts chosen bythe Clinton administration to review the planbefore its release, says the plan will besubstantially modified.

Blumenthal says the plan falls in the center ofRepublicans and Democrats, but that Clinton wouldhave to court the Republican faction in order forthe plan to succeed.

"I think he'll have to barter," he says. "Ijust hope he has the political skill to hold firmon the things he has to hold firm on."

Lee Professor of Health Policy and Managementat the School of Public Health Robert J. Blendonagrees with Blumenthal's analysis.

"He's going to have to involve people who aremore politically conservative," says Blendon."Some of the things in the plan that are moreregulatory will have to disappear."

Emanuel was impressed by Clinton's politicaltechnique in trying to convince Congress to passhis reforms.

"[Clinton's] going to say to the left that'It's my plan or nothing' and he'll say to theright 'It's my plan or Canada,'" he says. "It's amasterful stroke. The left will have to support itbecause they don't want nothing and the right willsupport it because they don't want Canada."

Blendon says a combination of taxes, phasing inthe program over a longer period of time, andmaking benefits less generous will probably benecessary to finance the plan.

"I'm a bit mixed about it," he says, echoingthe grab-bag of expert reactions to the plan.

Emanuel is less optimistic. "I am afraid thathe might discredit health care reform," he says.

If budget savings fail to cover the costs ofthe plan, argues Emanuel, universal access wouldhave to be phased in slowly, perhaps over eight toten years. And this, he says, may weaken Clinton'scase. "It doesn't give the people what theythought they were buying," he says.

Emanuel says Clinton's idea that most Americanswould get the same or better care, while payingthe same or less for it, seemed a bit tooidealistic. "[The idea] seems untenable, and mostAmericans know it," he says.

It appears, however, that at least one consumergroup will be lobbying for parts, if not all, ofthe plan. Michael L. Miller, policy director ofHealth Care for All, says his organizationsupported the plan's broad outlines, but not someof the details.

"Some specifics we are concerned about,probably foremost, the costs that will have to beborne by lower income people," Miller says.

Health Care for All, founded in 1986, consistsof more than 100 organizations in Massachusetts,including labor unions, senior groups, andneighborhood organizations.

"I am concerned about the politicalsurvivability of savings from Medicaid andMedicare," says Miller. "If the savings don'tmaterialize, the plan might unravel."

And Miller adds that he fears Congress may notlevy the necessary taxes to push the programthrough.

"A tax-based program is probably fairer," hesays. "You can scale taxes and relate taxes topeople's ability to pay."

Despite some qualms, Miller says hisorganization is enthusiastic after an auspiciousstart.

"We're energized, we're prepared, and we'revery excited to be doing this," says Miller. "Thisis the first time since Truman that we have aPresident willing to invest the political capitalin trying to reform the health care system."

And others who will be standing more or less onthe sidelines of the national debate that is sureto come on the heels of Clinton's Wednesday nightannouncement are eager to witness the future ofAmerican health care.

"I thought the speech was excellent as aspeech; however, I think parts of it sounded toogood to be true," says Kalkanis. "I don't thinkClinton spent enough time enumerating thesacrifices entailed."

Despite any reservations he has, Federman sayshe supports the plan. "It does not stop me fromwanting to see [the plan] worked on and carefullyimplemented," he says.

The need for reform may be the only item onwhich experts agree. But Clinton's speech was atleast a start, says Fein. "It was a call to arms,and it was very useful in that regard."

Steven G. Dickstein and Virginia A. Triantcontributed to the reporting of this article.The Health Care Plan at a Glance

What's Covered?

.Hospital services: diagnostic tests andX-rays, laboratory, bed and board, routine care.

.Professional services: physicians, nursepractitioners, chiropractors; includingpreventative care, inpatient and outpatientmedical and surgical services, periodic check-upsfor children and adults, specific screening tests,immunizations.

.Family planning and pregnancy related services(most likely including abortions)

.Alternative care: hospice care for terminallyill instead of hospitalization, home health careinstead of institutionalization.

.Prescription drugs: outpatient prescriptiondrugs covered; for people on Medicare, but whoaren't in an alliance, prescription drug benefitswith $250 deductible, 20 percent cost sharing,annual out-of-pocket cap of $1000.

.Vision and hearing care: eyeglasses andcontacts for children under 18, routine eye andear exams, diagnosis and treatment for eyedefects.

.Dental services: preventive services,emergency in jury treatment for children under 18.

.Mental health services: substance abuserehabilitation, inpatient and residentialtreatment; services only covered for 30 days perepisode, 60 days for in-patients; for outpatients,cap of 30 psychotherapy visits per year.

.Health education classes.

Who (And What) Pays?

.Employers must pay at least 80 percent ofpremium of average health care plan; paymentcapped at 7.9 percent of payroll, but employerscan choose to pay more.

.Government subsidies for employers who cannotpay 80 percent.

.Savings from Medicaid and Medicare programs.

."Sin" taxes on cigarettes and alcohol.

.Surcharges on large employers choosing to formtheir own alliance.

Who Saves?

.The uninsured--all Americans receive coverage.

.The poor--families and individuals withincomes below 150 percent of poverty level willreceive government subsidies to cover premiums.

.Retirees--government would pay premiums forthose not yet eligible for Medicare; existingemployer retirement health plans pay 20 percent ofpremiums, government pays the rest.

.Small businesses--those with up to 50employees can receive government subsidies basedon the average wage of the employees. If averagewage is under $12,000, the employer need notcontribute more than 3.5 percent. Employeecontributions increase with wages until themaximum cap of 7.9 percent.CrimsonSteven G. Dickstein

And some experts, while supporting theunderlying themes and message of the plan, saythere are more problems. For example, says Dr.Daniel D. Federman, dean for medical education atHarvard Medical School, the quality of care maynot be sufficiently championed in thenegotiations.

"I would like to see an explicit address topreserving quality and preserving education, andI'm concerned they are less well spoken for in thepresent design than universality, simplificationof paperwork, et cetera," he says.

And on the physicians' side, says one currentMedical School student, Clinton's plan may alsopose special potential problems for medicalstudents, including the freedom to choose theirarea of specialization.

Steve N. Kalkanis `93, a first-year MedicalSchool student, says the plan might require acertain number of graduates to become familypractitioners, thereby limiting the number ofresidencies in specialties. The cause for primarycare has been championed for several years, andsome organizations have called for a quota formedical school graduating classes of 50 percentprimary care physicians.

"As a med student, I'm still guarded and prettyskeptical," says Kalkanis.

But Kalkanis said he was comforted by Clinton'sreassurance that doctors were not the problem withthe health care system. "I'm somewhat relieved hemade an effort to emphasize that doctors weresomething good that should stay. He sent out amessage that he's not out to hurt the physiciansand the medical profession," he says.

Federman, who says he supports the underlyingprinciples of the plan, said he could not predict,as dean of medical education, what effectClinton's reforms would have on medical schools.

"Enrollment in medical school for six years hasbeen a growth industry, and the figures havealready surpassed those of last year," saidFederman. "What it will do in two years, smartdoctors don't predict."

Federman says he supports the plan's attempt tobreak the link between insurance and employmentstatus, its effort to control costs and especiallyits coverage of medication and long-term care forthe elderly.

He says the uninsured and the working lowermiddle class, whose coverage are often inadequate,would gain most from the plan. "The elderly willgain if prescription coverage is retained," hesays, "and those with job related insurance willgain because they will be free to carry insurancewherever they go."

Federman emphasizes the importance ofpreserving preventative medicine in the plan,citing the country's "very bad record inimmunization."

The dean is concerned that two of the plan'skey aspects remain uncertain: the costprojections, including the tax impact, and theapproach to managed competition.

Federman says he is unsure whether managedcompetition, which has never been tried, would beas promising as proponents hope. "The plan isterrific on access, very hard to interpret forcosts, and not explicit about quality," he says.

O Canada?

Criticisms by other public health experts,however, went more to the basic tenets of theproposal, such as its heavy reliance on employersto provide benefits.

Peter Hiam, former commissioner of insurance ofMassachusetts and now a professor at the BostonUniversity School of Public Health, said heopposes Clinton's employment-based system.

According to Hiam, it was a historical accidentthat employers provide insurance. During World WarII, there were price controls and employers gaveout health benefits. Ever since, employers havesimply continued to provide benefits.

Hiam is opposed to the employment-based systembecause it requires that each employer have anindividual insurance company, creating a "needlesscomplication."

"The system we have is a nightmare [because itis so] complex," says Hiam. "I'm not belittlingthe potential for improvement. What's a shame isthat [Clinton's] not being so bold to simplify andmake the system more fair."

But more specifically, Dr. Ezekiel J. Emanuel,assistant professor of medicine and of socialmedicine at Harvard Medical School, says hedoubted a simplified form for patients wouldimprove quality.

"Everyone who knows anything about improvingquality knows you will have to have more forms,[not fewer], in assessing patient outcomes," hesays.

Hiam says he thinks Clinton endorses anemployment based system because of state politics:it is the easiest method by which to please asmany people as possible, he says.

And Rashi Fein, professor of economics ofmedicine at the Medical School, while callingClinton's speech an excellent "call to arms," saysa single payer system, similar to Canada's, wouldhave been a better choice. Universal insurancewould not be paid by employers, but by abroad-based tax based on ability to pay, in aversion of Canada's much-touted health caresystem.

"Think of it as free public education. Everyonegets it, but we don't base it on who you workfor," he says. "The plan would have been simpler,and we wouldn't have had to compress evolutionarychanges into a revolutionary time period."

Fein also says that the plan's financing,largely based on expected savings, would not comequickly enough. "Clinton will be under pressure tolet the deadline slip a bit."

Calling The Odds

What remains unclear is the plan's chances forpassing the difficult hurdle of Congress. Dr.David Blumenthal '70, chief of health policyresearch and development at the MassachusettsGeneral Hospital, says the commitment to universalhealth care, cost containment, and the opportunityfor physician choice are essential for the plan'spassage in Congress.

Like other experts, Blumenthal, who was one of47 non-government health policy experts chosen bythe Clinton administration to review the planbefore its release, says the plan will besubstantially modified.

Blumenthal says the plan falls in the center ofRepublicans and Democrats, but that Clinton wouldhave to court the Republican faction in order forthe plan to succeed.

"I think he'll have to barter," he says. "Ijust hope he has the political skill to hold firmon the things he has to hold firm on."

Lee Professor of Health Policy and Managementat the School of Public Health Robert J. Blendonagrees with Blumenthal's analysis.

"He's going to have to involve people who aremore politically conservative," says Blendon."Some of the things in the plan that are moreregulatory will have to disappear."

Emanuel was impressed by Clinton's politicaltechnique in trying to convince Congress to passhis reforms.

"[Clinton's] going to say to the left that'It's my plan or nothing' and he'll say to theright 'It's my plan or Canada,'" he says. "It's amasterful stroke. The left will have to support itbecause they don't want nothing and the right willsupport it because they don't want Canada."

Blendon says a combination of taxes, phasing inthe program over a longer period of time, andmaking benefits less generous will probably benecessary to finance the plan.

"I'm a bit mixed about it," he says, echoingthe grab-bag of expert reactions to the plan.

Emanuel is less optimistic. "I am afraid thathe might discredit health care reform," he says.

If budget savings fail to cover the costs ofthe plan, argues Emanuel, universal access wouldhave to be phased in slowly, perhaps over eight toten years. And this, he says, may weaken Clinton'scase. "It doesn't give the people what theythought they were buying," he says.

Emanuel says Clinton's idea that most Americanswould get the same or better care, while payingthe same or less for it, seemed a bit tooidealistic. "[The idea] seems untenable, and mostAmericans know it," he says.

It appears, however, that at least one consumergroup will be lobbying for parts, if not all, ofthe plan. Michael L. Miller, policy director ofHealth Care for All, says his organizationsupported the plan's broad outlines, but not someof the details.

"Some specifics we are concerned about,probably foremost, the costs that will have to beborne by lower income people," Miller says.

Health Care for All, founded in 1986, consistsof more than 100 organizations in Massachusetts,including labor unions, senior groups, andneighborhood organizations.

"I am concerned about the politicalsurvivability of savings from Medicaid andMedicare," says Miller. "If the savings don'tmaterialize, the plan might unravel."

And Miller adds that he fears Congress may notlevy the necessary taxes to push the programthrough.

"A tax-based program is probably fairer," hesays. "You can scale taxes and relate taxes topeople's ability to pay."

Despite some qualms, Miller says hisorganization is enthusiastic after an auspiciousstart.

"We're energized, we're prepared, and we'revery excited to be doing this," says Miller. "Thisis the first time since Truman that we have aPresident willing to invest the political capitalin trying to reform the health care system."

And others who will be standing more or less onthe sidelines of the national debate that is sureto come on the heels of Clinton's Wednesday nightannouncement are eager to witness the future ofAmerican health care.

"I thought the speech was excellent as aspeech; however, I think parts of it sounded toogood to be true," says Kalkanis. "I don't thinkClinton spent enough time enumerating thesacrifices entailed."

Despite any reservations he has, Federman sayshe supports the plan. "It does not stop me fromwanting to see [the plan] worked on and carefullyimplemented," he says.

The need for reform may be the only item onwhich experts agree. But Clinton's speech was atleast a start, says Fein. "It was a call to arms,and it was very useful in that regard."

Steven G. Dickstein and Virginia A. Triantcontributed to the reporting of this article.The Health Care Plan at a Glance

What's Covered?

.Hospital services: diagnostic tests andX-rays, laboratory, bed and board, routine care.

.Professional services: physicians, nursepractitioners, chiropractors; includingpreventative care, inpatient and outpatientmedical and surgical services, periodic check-upsfor children and adults, specific screening tests,immunizations.

.Family planning and pregnancy related services(most likely including abortions)

.Alternative care: hospice care for terminallyill instead of hospitalization, home health careinstead of institutionalization.

.Prescription drugs: outpatient prescriptiondrugs covered; for people on Medicare, but whoaren't in an alliance, prescription drug benefitswith $250 deductible, 20 percent cost sharing,annual out-of-pocket cap of $1000.

.Vision and hearing care: eyeglasses andcontacts for children under 18, routine eye andear exams, diagnosis and treatment for eyedefects.

.Dental services: preventive services,emergency in jury treatment for children under 18.

.Mental health services: substance abuserehabilitation, inpatient and residentialtreatment; services only covered for 30 days perepisode, 60 days for in-patients; for outpatients,cap of 30 psychotherapy visits per year.

.Health education classes.

Who (And What) Pays?

.Employers must pay at least 80 percent ofpremium of average health care plan; paymentcapped at 7.9 percent of payroll, but employerscan choose to pay more.

.Government subsidies for employers who cannotpay 80 percent.

.Savings from Medicaid and Medicare programs.

."Sin" taxes on cigarettes and alcohol.

.Surcharges on large employers choosing to formtheir own alliance.

Who Saves?

.The uninsured--all Americans receive coverage.

.The poor--families and individuals withincomes below 150 percent of poverty level willreceive government subsidies to cover premiums.

.Retirees--government would pay premiums forthose not yet eligible for Medicare; existingemployer retirement health plans pay 20 percent ofpremiums, government pays the rest.

.Small businesses--those with up to 50employees can receive government subsidies basedon the average wage of the employees. If averagewage is under $12,000, the employer need notcontribute more than 3.5 percent. Employeecontributions increase with wages until themaximum cap of 7.9 percent.CrimsonSteven G. Dickstein