Let's Play Doctor

Politicians of both parties say managed care is an increasingly hot issue. The question now: Will they just fight over it or actually try to do something?

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Most voters like what they have seen coming from Washington in recent years: legislation that lets people keep their health benefits when they change jobs; that spends $24 billion to provide medical care to uninsured children; that requires Medicare to cover preventive screening for breast cancer, colon cancer and osteoporosis. The fact that at least two-thirds of the states moved ahead on reining in managed care has only increased the call for action on the federal level, because more than 40% of the U.S. population is covered under health plans outside the reach of state regulation.

Though health care has once again found its way onto the political map, the landscape has changed profoundly since Clinton launched his health-care crusade in 1993. In that unsteady economy, the question at hand was containing out-of-control costs and covering the 36 million Americans who lacked health insurance. That number has grown in the past four years. But with fewer people worried about losing their jobs and the health benefits that go along with them, the uninsured and their tragic stories barely figure in the debate. Instead, politicians have taken up the cause of the Great Insured Majority against the employers, HMOs and insurance companies that would deny them proper care. "How can you let some person with the mentality of an accountant...make the decision?" Clinton has demanded.

Traditional battle lines have been erased as well. The doctors who fought Hillary's health plan so fiercely in 1994, then sided with Newt Gingrich on Medicare in 1995, are now allied not only with Clinton but also with their sworn enemies, the trial lawyers. Both groups want to give patients the ability to sue their health plans for improper treatment. And the neat ideological divide between pro-business Republicans and populist Democrats is breaking down as well: some of the most conservative Republicans, including South Carolina's Lindsey Graham and Steve Largent of Oklahoma, are on record favoring some of the most liberal legislation. These Republicans don't like corporate bureaucracies any more than they like government ones.

Clinton was the first to recognize how ripe a target managed care had become. In 1996 he seized on protecting mothers and their newborns against health plans that forced them out of the hospital only hours after delivery. Republicans, led by New York Senator Alfonse D'Amato, quickly trumped the campaign against "drive-through deliveries" with their own legislation against "drive-through mastectomies." And soon G.O.P. rank-and-filers such as Georgia Congressman Charlie Norwood, a dentist, and Iowa's Greg Ganske, a plastic surgeon, were out ahead of most Democrats in fomenting a broader assault on managed care.

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