In Sickness and in Health: Hillary Clinton Takes Charge.

By Frank Marafiote

At first it looked like a lost episode from Mission Impossible: overhaul the nation's chaotic, $915 billion health care system, extend medical coverage to 37 million uninsured Americans, and deliver a finished proposal to the president in 100 days.

Few political observers believed Bill Clinton did the First Lady any favors by appointing her chairwoman of the President's Task Force on National Health Care Reform. Not only is Hillary Rodham Clinton overseeing the most complex social issue facing the Administration, her own place in history seems to be at stake as well.

Although most Americans initially approved of the president giving her this new role, many also expressed a "wait-and-see" attitude. Would Hillary Clinton prove to be the politically-savvy policy manager everyone said she was? To a large degree, the Task Force has become the playing field on which that question is being answered. There is also a sense among many women that Mrs. Clinton's success or failure ultimately will carry its imprint on them as well.

From the outset, the First Lady's road to health care reform has proven rockier than anticipated. Some of the bumps along the way: power struggles within the Task Force among policy advisors with competing viewpoints, the enormous complexity of the health care system itself, and Mrs. Clinton's own health care crises with the sudden illness and death of her father, Hugh Rodham.

The first goal to fall has been President Clinton's 100-day deadline. In early April, the White House told HCQ that while Mrs. Clinton's visits to her father's bedside in Little Rock have certainly slowed the process, the delay is primarily due to the vast amount of material the Task Force must review before selecting the key elements of the final proposal.

With little more to go on than an occasional trial balloon floated by the Administration, media attention has often centered on Mrs. Clinton's own political agenda and working style. The way she gets the job done remains as significant to many people as the final recommendations of the Task Force.

Mrs. Clinton has generally received high marks for the role she has played thus far. "She does things a little differently than other policy managers," a congressional legislative aide tells HCQ. "She picks up the phone and personally calls senior members of Congress at home, both Republicans and Democrats. She's a quick study and people have been impressed with her level of knowledge on the health care issue."

Supporters of Mrs. Clinton are also quick to point out that health care reform is not the typical "safe" issue addressed by former First Ladies. "Nancy Reagan and Barbara Bush had no pro-illiteracy or pro-drug abuse lobby to contend with," says a Democratic staffer. "On the other hand, the health care lobby is one of the most formidable in Washington."

Suzanne Fields, a Washington Times columnist and frequent critic of Mrs. Clinton, admits that the First Lady has come across as a "very strong person" during her trips to the Hill, and is spoken of "very respectfully" by staff members.

Not everyone, of course, shares that viewpoint. Syndicated columnist and lecturer Cal Thomas tells HCQ, "When liberals mean reform, they mean diminished excellence. No matter what she (Hillary Clinton) does, she won't get the poor to stop smoking, lose weight, exercise more, give up fatty foods, or keep hypochondriacs from showing up at the hospital to be treated for hang-nails."

Thomas also faults Mrs. Clinton for holding Task Force meetings in secret. Lack of public access, he says, "is a clear indication that she has something to hide, namely her socialistic agenda." Others have complained about the composition of the Task Force. Of the 511 members, none are doctors or hospital administrators, and over 90% are federal employees, primarily from Democratic congressional staffs.

Notwithstanding such complaints, health insurance executives, as well as officials from the American Medical Association and others in the health care industry, have reportedly met frequently with top Task Force advisors, including Mrs. Clinton and policy coordinator Ira Magaziner. Perhaps to counter concerns about her personal influence, the First Lady at one point emphasized that her job was "to make sure that we fulfill the president's directive."

While many of the Task Force recommendations are still being determined, it appears likely that the final proposal will neither confirm the worst fears of conservatives nor totally delight those who want radical reform. During one of Mrs. Clinton's visits to her father in Little Rock, Ira Magaziner addressed a conference in in Washington and outlined a proposal that can best be described as a patchwork of competing economic and political philosophies.

Rather than a totally centralized national health care system, Magaziner said that states will be given some flexibility in carrying out federal mandates. Managed competition -- the idea of large purchasing networks in which health care providers bid for contracts with employers and consumers -- will remain the basic philosophy of the plan. Likewise, the plan will specify a core package of services to be guaranteed for every American, as well as an overall budget to better control health care costs.

Within those general guidelines, however, states and consumers will be free to choose from a variety of options, including single-payer systems in regions where managed competition is not practical, managed care via HMOs, and traditional "fee-for-service" programs.

Absent from the plan outlined by Magaziner was any hint that Hillary Clinton's "leftist political agenda" -- as some conservative commentators have described it -- unduly influenced the Task Force. Indeed, his comments suggest a deliberate, if not torturous, attempt to create a health care system that embodies a diversity of viewpoints.

Several key forces appear to be at work: the desire to maintain a traditional balance between federal and state roles; the realization that health care resources vary considerably from state to state; and the political reality that passage of a plan is more likely if states are given some flexibility and control during implementation.

Critics might argue, however, that the plan outlined by Magaziner will further complicate, not simplify, an already chaotic system; that it will create enormous and inefficient bureaucracies at the federal and state levels to manage the plan; that implementation will take longer than expected as states grapple with various options; that the Task Force apparently has been unable, or unwilling, to make tough prescriptive choices among competing recommendations; and that too many interest groups -- including the health care lobby -- have ultimately shaped Task Force recommendations.

Some health care analysts are also likely to fault the Task Force for not being bold enough in its recommendations. "The biggest mistake they can make is not to take advantage of public goodwill to make radical reform," says Dr. Phillip Caper, Professor of Public Policy at Dartmouth Medical School and lecturer on Health Policy and Management at Harvard University. "There's a chance the plan will be too timid," he says. A lack of boldness would be apparent, Dr. Caper tells HCQ, if the Administration proposes new taxes to pay for reform. "If they have to increase taxes, they're missing an opportunity to use resources efficiently. We're already paying too much for health care."

Cathy Schoen, who served on President Carter's task force for national health insurance, agrees with Dr. Caper. "Incremental change won't work," she contends. "Moreover, we can achieve health care reform and do it with what we're spending now. We need a vehicle that funnels all the funds we're now spending on health care into a single pool."

While Ms.Schoen and Dr. Caper dispute the need for new taxes, both tell HCQ that they expect -- and would welcome -- a Task Force proposal that gives states flexibility in implementing a national plan, as well as a global health care budget and short-term price controls.

Professor Michael Porter of the Harvard Business School, who participated at president-elect Clinton's economic summit in Little Rock last December, says he is encouraged by the "massive research project" being conducted by the Task Force. He is less encouraged, he tells us, by the emphasis on managed competition. Calling it "simplistic," he believes managed competition will do little to reduce health care costs. "It just doesn't go far enough," he says. "There are no real incentives to reduce costs."

Professor Porter contends that the impact of Hillary Clinton's Task Force will likely be modest. "Victory," he says, "will simply mean that in the future health care costs increase less rapidly. Costs won't go down." He also predicts that the health care industry, which currently competes on the basis of service and technology, will be forced in the future to compete on the basis of price and productivity.

Soon after Hillary Clinton was appointed chairwoman of the Task Force, Howard Fineman, commenting on PBS's Washington Week in Review, called national health care reform a social "Manhattan Project." Others have described it as the most complex social issue since the 1930s when President Roosevelt created the social security system.

Perhaps no one knew better than Hillary Clinton how great a challenge reform would be. Two weeks after accepting this "mission impossible," she told a conference in Pennsylvania, "It is a very difficult change to bring about. The people who believe in changing the whole system ought to understand how difficult it is going to be to change even small parts, because of the interests that are arrayed against those changes."

 

 

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