MISSOURI COMMENTARY: MANAGED CARE: BILL VS. NEWT

What a difference a year and an election make! Think back to 1994. President Bill Clinton and his wife were trying to sell their national health care plan to Congress and the American people. The twofold rationale for their proposal was (a) the equity of making adequate medical treatment a right for all rather than a privilege for many and (b) the need to bring health care costs under control.

The price of medical care was exploding at a rate far in excess of normal inflation. The impact on federal and state budgets in providing ever more expensive health services to the elderly (Medicare) and the poor (Medicaid) was reaching crisis proportions.

The Clinton solution was a network of managed care entities called "alliances." These "alliances" would compete with each other in offering quality health care at virtual wholesale rates to large group of people. The ultimate purpose, amongst other things, was to reduce the nation's over dependence on fee-for-service medical treatment, the most expensive form of health care delivery. With respect to Medicare beneficiaries, 90 percent is fee-for-service medicine. According to the experts, that is a principal component of the continuing explosion in the costs of the Medicare program.

The Republicans strenuously opposed the complex Clinton plan. It was denounced as government intervention at its worst. Minority Leader bob Dole land then Congressman Newt Gingrich claimed that Americans had the finest health care system on the face of the earth. It wasn't broke; it did not need fixing. It only needed a little tinkering and fine tuning at the margins.

Central to the Republican opposition was the notion of an inalienable right for any American to choose any doctor and any hospital he or she wanted anywhere in the United States. Managed care or HMOs give members lists of hundreds of physicians and dozens of hospitals from which members make their selections. Managed care systems are able to provide health services at greatly reduced costs by reason of their ability to contract with doctors and hospitals on a high volume basis. The Republican scoffed at any form of managed care. The Clinton health plan, weighed down by a multitude of political burdens, ultimately crashed.

Now it is a year and an election later. The same people who were instrumental in bringing down the Clinton proposal are now in charge of the Congress. They now have the responsibility to address at least one facet of the health care delivery system, Medicare. They need to cut Medicare payments in order to try to balance the budget, to pay for their tax cut and to save the Medicare system from bankruptcy.

The clearest way to get big savings in physicians' fees is to somehow shift Medicare participants out of fee-for-service medicine into managed care. The Republicans have to do this year what Bill Clinton tried to do last year. They are having a dreadful and anguished time figuring out how to do it.

As for President Clinton, he has his own program to avoid the bankruptcy of Medicare. His savings figure comes in at $124 billion. Clinton has strongly criticized the Republican approach. Among other things, he faults it because "it would reduce doctor choice." That is a line he may well have lifted from a 1994 speech of Senator Dole criticizing the Clinton health plan.

There is nothing senators and congressmen fear more than the wrath of the elderly. There is no segment of the American electorate in which the warning sounds of danger lurking ahead can be disseminated so effectively. Nothing in American political life compares to the grassroots of the senior citizen network.

The Republicans in Congress, amongst some of the most tuned-in political minds in the country, realize that in changing Medicare they are playing with political dynamite. They can't force senior citizens in less expensive managed care because they said that was a no-no last year when they opposed Clinton. Yet Republicans also know that unless overwhelming numbers of the 37 million Medicare recipients switch to managed care, much of the anticipated cost savings they seek will not take place.

One should contrast the different way in which Medicare beneficiaries at all economic levels are treated as opposed to impoverished Medicaid recipients under 65 years of age. Medicare participants, it is hoped, will on their own volition help the country and go into managed care. Medicaid beneficiaries under 65 are ordered to pick one of seven managed care programs and, if you don't select one, the State of Missouri will dump you into one. Take that, buster, and like it. This is considered fiscally prudent and is generally applauded as sound public policy by people of all ages who live in the suburbs.

~Tom Eagleton of St. Louis is a former U.S. senator from Missouri.