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Health care red herrings

"Red herring" used to refer, literally, to the use of a pungent fish to draw tracking dogs off a scent. It has since become one of our most expressive political metaphors.

There are plenty of red herrings to be seen _ or, rather, smelled _ in the health care debates under way at Washington and Tallahassee.

These red herrings are the claims that President Clinton's program is "too complex," that it will lead to rationing of care, and that people could no longer choose their own doctors.

There is some truth in all three points. It is how they are being manipulated by the opponents of change that makes them reek. The future they would have us fear is now.

At 1,364 pages, Clinton's Health Security Act is undeniably complex. But complexity is sometimes a necessary safeguard against failure _ as in, say, the designs and specifications for passenger jets, nuclear submarines and moon rockets. Clinton's legislation appears complex, the Congressional Budget Office has pointed out, only because it details "the steps that would actually have to be taken to accomplish its goals.

"No other proposal," said the CBO, "has come close to attempting this. Other health care proposals might appear equally complex if they provided the same level of detail as the administration on the implementation requirements."

Where the complexity really hurts Clinton is in the difficulty of explaining the plan to the public in 25 words or less. What people don't understand they won't support. But suppose he had said, "Let's just extend Medicare to everyone."

It's also true that the day is fast approaching when few Americans will be able to choose their own doctors and when anonymous bureaucrats will ration the care they receive. But for many if not most of us, that day is already dawning without the Clinton plan or its competitors.

The $900-billion a year presently being spent on health care is already being severely rationed. As Doug Cook, Gov. Lawton Chiles' health care administrator, puts it, "We ration people." No expense is spared for those who are wealthy or well-insured. Those who are desperately poor enough for Medicaid can sometimes do nearly as well, depending on where they live. But the many millions who are uninsured or underinsured have to be desperately ill before they can be treated, and they are more likely to die. If America's medical expertise is the envy of the world, our longevity and infant mortality rates are not.

Our tax system, meanwhile, allows people who are fortunate enough to have insurance at work to treat the employer's share (and often their own) as wages exempt from payroll and income taxes. The $75-billion a year that this subsidy costs the Treasury is, in effect, a tax on those who aren't fortunate enough to have employer-paid insurance. That's rationing transmogrified into robbery.

Rationing is a reality even to those who have insurance. As the Wall Street Journal recently wrote, "unlimited choice of doctors is steadily going the way of house calls." In only five years, the percentage of people enrolled in fee-for-service plans (the kind where you can choose any doctor or hospital) has shrunk from 71 to 49 percent. Even when such plans are available, the copayments and deductibles may be deliberately prohibitive. In steering workers into plans that restrict choice, employers are merely trying to ration their health care dollars. Clinton's plan would actually give workers more choice in the form of a wider variety of insurance plans than many companies now offer.

The real issue isn't whether we're going to ration but how straightforwardly _ and, if you please, rationally _ we do it. Now, who would you rather trust to make your health care budget? Politicians we elect, deliberating in public? Or corporate personnel directors, talking privately to insurance executives who, like the Cabots of Massachusetts, talk only with God?

In Florida, meanwhile, the Florida Medical Association, trying to win what it lost in last year's debate, opened a campaign last week to pressure the Legislature to gut the reforms Chiles secured last year.

Specifically, the FMA says doctors should be allowed to join any health plan they choose, so long as they meet its minimum qualifications and are willing to settle for its prescribed fees. Superficially, the argument is appealing. Why not let them, and their patients, have that choice?

What it really means, though, is that doctors could jump from plan to plan whenever administrators tried too hard to manage costs or quality of care. The plans would lose the only leverage they have now, which is to offer selected doctors a high volume of patients in exchange for lower fees.

There is, as it happens, a proven system that insures everyone, allows patients total freedom of choice in selecting their doctors and does away with insurance companies in the bargain. I wonder if the FMA would be interested.

The Canadians call it Medicare.

Martin Dyckman is associate editor of the Times.

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