Not so long ago Americans spoke up and rejected a government takeover of our health care system. Today many federal and state legislators, regardless of their political stripes, are passing feel-good legislation in an effort to demonstrate politically correct compassion.

A Republican Congress and Democratic White House are inching toward many of the massive objectives put forth by the Clinton Health Care Task Force. This time there is no formal plan and very little media coverage, but there is a step-by-step agenda.

Step One: Integrated Health Care Networks

 WHAT CLINTON WANTED: Health plans were to form integrated networks of hospitals and doctors at a fixed price. WHAT CLINTON GOT: Community hospitals are selling out to giant corporations, destroying a valued community resource and employer. We have seen HMOs become insurers and owners of hospitals and we have seen insurers become owners of hospitals and HMOs. So, how integrated have we become? In less than four years Columbia/HCA grew from a two hospital system to a 346 hospital chain in 20 states. Quorum Health Group now owns 19 hospitals while managing 241 and Tenet Healthcare owns 148 hospitals. As integrated medical networks grow, a few companies remain to dominate the medical market place, creating nothing less than a medical monopoly.

Step Two: Guaranteed Issue

WHAT CLINTON WANTED: All U.S. citizens and legal immigrants were to be entitled to health care insurance regardless of job or health status. WHAT CLINTON GOT: In a pre-election display of political compassion, Congress enacted the Kassebaum-Kennedy bill. The Health Insurance Portability and Accountability Act (HIPAA) forces insurance companies to provide coverage to individuals regardless of their health. Although states retained some flexibility for complying to HIPAA mandates in conservative ways, the bottom line remains: guaranteed issue will increase the cost of premiums for everyone, increase the number of uninsured and will force many insurers to abandon a hostile marketplace.

Step Three: National Health Policy Board

WHAT CLINTON WANTED: A large government agency and health board to oversee all aspects of national health care. WHAT CLINTON GOT: Early this year Clinton announced the formation of a National Commission on Health Care Quality. Donna Shalala leads a 20 member team consisting of the same “consumer advocates” who fought in favor of the original Clinton plan. The commission is made up of insurers, who will sit in judgment of their own cause; labor leaders, who support a single payer health care system; and business leaders who want to transfer the cost of corporate retirees onto the federal taxpayer.

The October 1997 draft of the Patient Bill of Rights contains all the regulatory features of ClintonCare-1. This time around, instead of referring to “universal” health care coverage, the repackaged ClintonCare-2 refers to “minimum national standards.”

The standards, redefined for more popular appeal, still mean Health and Human Services (HHS), the Department of Labor (DOL), the IRS, and the Health Care and Financing Administration (HCFA) get to decide who gets what health care and when and if they get it. Their new politically correct dictionary includes terms like: “Non-discrimination on the basis of health status,” read guaranteed issue; “Non-discrimination of the basis of income,” read community rating and price controls; “Access to certain basic benefits,” read a mandated benefits package; “Access to women’s health services,” read abortion coverage; and “Access to specialists without referral,” read any willing provider mandate.

The practical result will be the same: enactment of Clinton incrementalism whereby he gets his entire Health Security Act before he leaves office.

Step Four: Guaranteed Benefits

 WHAT CLINTON WANTED: Guaranteed health benefits to include, hospital care, pregnancy care, hospice care, emergency care, prescription drugs and mental health coverage parity with any other illness. WHAT

CLINTON GOT: Imposing unfunded federal mandates for minimum hospital stays for birthing mothers and providing mental health care on a parity with any illness pales in comparison to the mandates accomplished at the state level. Over one thousand guaranteed benefits laws, including special interest benefits like toupees and

invitro-fertilization, are in place today, costing health care consumers an estimated $60 billion a year.

Step Five: Medicare Reform

WHAT CLINTON WANTED: The elderly could enroll in Medicare or move to managed care health plans. WHAT CLINTON GOT: Left to its own devices, Congress will destroy the Medigap market by “urging” seniors to join federally regulated managed care plans as a cheap alternative to Medicare with private Medigap supplement insurance. What seniors don’t know is that in exchange for a few premium dollars, seniors loose the ability to choose health care options outside of restrictive managed care plans.

Further Medicare reform was buried in the 1997 budget reform bill. This little known provision establishes a health care system in which the non-elderly can freely contract for private medical services, but those over 65 may not. This was the same method used in Canada to kill private medicine without a straightforward law barring citizens from spending their own money on medical services. Ultimately, Canadian doctors who “opted” out of government care were unable to attract enough patients willing to forgo a government entitlement. The physicians either reluctantly agreed to socialized medicine or migrated to the United States.

Step Six: Medicaid Reform

WHAT CLINTON WANTED: To eliminate the Medicaid program and let the government pay for the poor to join managed care HMOs. WHAT CLINTON GOT: States are forcing Medicaid beneficiaries out of fee-for-service health plans into Managed Care Plus plans. Whether this cost-shift to the states actually saves money remains to be seen. What is clear is that beneficiaries have the same complaint as the non-Medicaid population joining a managed care plan: the quality of health care is being compromised for a price.

Step Seven: Kid Care

WHAT CLINTON WANTED: A national health care plan that covered everyone, including 10 million uninsured kids. WHAT CLINTON GOT: Congress recently provided $24 billion in a grant-match program that guarantees the creation of another massive medical bureau-cracy, despite the fact that there may not be 10 million uninsured kids and despite the fact that private sector health insurance for children is both inexpensive and available. Worse, most state and federal legislators seem to be unaware that insurers like Blue Cross and Kaiser Health Plans already offer means tested KidCare health insurance with coverage to age 18. At the low end of the cost spectrum, Blue Cross (Missouri) charges a yearly premium of about $360 per child while Kaiser Permanente (California) charges about $800.

Considering the $24 billion the federal government is spending on this new entitlement, political compassion is coming at a high price. If you do the math, the federal KidCare per child cost is about $2,400 a year compared to the private alternative of about $360 in Missouri to $800 in California.

Step Eight: Managed Competition vs. Managed Care

WHAT CLINTON WANTED: A national health board to regulate a managed competition system of health plans competing for customers and providing coordinated care. WHAT CLINTON GOT: Most workers in America are now covered by a managed care plan of coordinated care that is being regulated or influenced by state legislators, the federal government and the new National Health Policy Board.

Step Nine: National Medical Database

 WHAT CLINTON WANTED: A Department of Justice agency to track the behavior of doctors and patients and prosecute whenever the behavior did not meet federal guidelines. This notion of medical cops became a major issue during the healthcare debates. WHAT

CLINTON GOT: HIPAA establishes an expansive data collection apparatus at the federal level, including storage and dissemination of patient records as well as assigning “patient identifier” codes. The obscured provision creating a privacy-threatening national medical database was lifted almost word-for-word from the original Clinton health care plan. The anti-fraud provisions in HIPAA establish draconian penalties for doctors and patients who make honest paperwork errors when trying to understand complex forms and procedures. The entire medical profession, including patients, will be watched by the Department of Justice. Does George Orwell’s 1984 come to mind?

The Final Step

WHAT CLINTON WANTED: To expand use of Medicare as a method for delivering, influencing and regulating health care for the indigent, uninsured children, and others numbered in the “uninsured” population. WHAT CLINTON GOT: A favorable political health care reform climate for establishing cradle-to-the-grave health care. So much so, that expansion of Medicare is being viewed

by many as a positive step towards bringing hundreds of thousands more citizens under federal health care control along with their millions of dollars in premium.

The real problem with Medicare is that it collects, on average, $1 in premium for every $5 in benefits distributed. That’s the deal of the century for individuals who can afford the cost and have existing health problems. They would consume Medicare health dollars that simply do not exist.

Of all the questions surrounding this issue, one question goes begging: How long will it take before the eligibility age is lowered to 45, to 25, to birth?

Bill Clinton, not one to reveal his hand very often, has clearly stated his continuing health care reform agenda. On September 15, 1997, in a speech to the Service Employees International Union, he said, “If what I tried before won’t work, maybe we can do it another way. That’s what we’ve tried to do, a step at a time, until we eventually finish this.”

This step-by-step, piecemeal health care reform agenda has become the road to hell. And while this road may be paved with good intentions, it still leads to hell. Have we forgotten freedom is rarely ever lost in a single legislative action, but disappears in small incremental, hardly noticeable steps?

It’s time to stand up and be counted, again.

Mr. Meier is health policy advisor for The Heartland Institute. His address is 309 Vieux Carre Court, Columbia, MO 65203-0059. (573) 445-3023. E-mail: villicus@socket.net

Originally published in the Medical Sentinel 1998;3(3):92-93. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).