European Stars and Stripes (Newspaper) - January 5, 1994, Darmstadt, Hesse Wednesday january 5, 1994 commentary the stars and stripes Page 13 David s. Broder As the debate on health care unfolds in the coming months it will be Well to remember that there is Good reason for people to be arguing at Cross purposes. Any major change in a system that consumes one seventh of the nations annual output will produce Large scale winners and Osers. If you understand the. Economic self interest at stake you can better gauge the policy argument being made. Uwe e. Reinhardt a health policy expert at Princeton University in new Jersey gave a Good example of this Point in testimony to the House ways and Means committee just before the holidays. Splits within industries that Are puzzling at first glance make perfect sense if you understand the economic interests at play. Take doctors for example. Shortly before Reinhardt testified the american medical association whose policy making is dominated by medical specialists backed away from its support of employer mandates the administrations Way of paying for Universal health insurance. Within a few Days the White House assembled leaders of other physician groups a mainly representing general practitioners a to say that the Ama was off base Ana that the administration plan was right. What was going on both sides Reinhardt a analysis suggests were doing the sensible thing of protecting their own interests. A a major shift from the traditional fee for service system. To one based on managed Competition with managed care As the administration proposes would imply a concomitant conversion of physicians from self employed to employed professionals a he said. A that conversion could have momentous economic consequences for physicians in general arid for medical specialists in particular. A the traditionally higher incomes of medical specialists and the relatively higher rate of return to their own investment in education and training would be unlikely to persist. In the end their incomes would be Likely to move closer to those of primary care physicians whose incomes can be expected to Rise under managed Competition although probably not to full there you have it a in Stark economic terms a camouflaged by rhetoric. Under the Clinton plan specialists who now can often set their own fees Are Likely to become employees of health maintenance organizations. The mos can bargain effectively on their wages because the Large number of available specialists will make this a buyers Market. By contrast general practitioners a or primary care physicians As the jargon has it a will be much in demand. Because their ranks Are thinner their wages from the mos will approach those the specialists command. There a a similar split in the ranks of the insurance Industry. The health insurance association of America representing mainly Small and medium sized com panics has been running an and Campaign critical of the Clinton plan which Nas drawn Strong counter fire from the White House. More recently the Alliance for managed care representing a handful of the giants in on n a it of i need Nour he my 0ack. some Ftp no wrong with my pack. My Arm. There a something wrong w to my Arm. Fro m carrying 37 Mllton americans without health a a insurance or from _ cutting through mountains of health care paperwork c my heart. There a something wrong with my heart. L its Blush no. For. R americans who Are 0ankrupted sprocket a amp 7 Neath Heru what you need Topo. My eyes. Theres something my i health insurance has started its own ads backing the presidents approach. Why the split in Reinhardt a Blunt economic analysis if anything resembling Clinton a managed Competition plan is enacted a Many Small or medium sized health insurance companies and their network of brokers Are Likely to withdraw from that line of business in the a the Large insurance firms however. Would continue to have a lease on life under managed Competition. They would organize and manage some of the accountable health plans. In the process they would replace their current armies of marketeers and brokers with a new Breed of professionals who know How to control utilization and costs within a health plan who know How to bargain with doctors hospitals and others Selling goods or services to the plan who know How to keep enrolled patients Happy and who know How to keep clinical Quality High a at least in although Reinhardt did not make the Point in this testimony a similar economic imperative drives the positions being taken by business groups. Large corporations with generous employer paid health plans and big expenses for covering the medical needs of their retirees Chrysler corp., for example stand to reap a Bonanza from the Clinton Bill and Are correspondingly enthusiastic about it. Start up firms with Youthful work forces and few retirees Are Likely to find their costs increased. Those Small businesses that cur Renty do not provide health insurance to their workers will obviously face new charges. All this is not cynicism. It is simply the Case that health Reform will produce big winners and losers. What makes Congress task a Tough one is deciding who takes the hit and who comes out ahead. C Wshington Post writer group americans finally started warming up to president Clinton in the past few weeks Only to be reminded almost immediately of the doubts he a tried All year to dispel. Clinton a approval rating soared into the upper 50s in several year end polls a a Good showing by any Standard. But he a also dipped to record lows and maintained High negative ratings during his first year in office. And that was before the so called character Issue blew into the headlines again when two members of his Arkansas Security detail went Public with detailed allegations of marital infidelity by Clinton. And it was before the arrest of his surgeon general a son on drug charges before the disclosure that his acclaimed Pentagon Choice did not pay social Security taxes on household help and before new questions about his involvement in a failed Arkansas savings and loan. Recently Clinton pollster Stan Greenberg tried to explain his clients volatile ratings this Way a the impressions at the outset particularly with this pm i president were quite shallow. I think there is now developing a much Richer image of the president but still unfolding. To which another pollster Pat cad Dell replied a this president has a problem. There Are a lot of severe doubts that go All the Way Back to the Trust has been an underlying problem for Clinton since january 1992, when he was first dogged by questions about his marriage and his draft record. Lingering reservations about his character Are a big reason a the Hasni to wormed his Way into the american psyche a said Bruce Buchanan a presidential scholar at the University of Texas. Strong performances by both Clinton and the Economy have at least partially Jill Lawrence my wary offset that damage setting off his late breaking min surge in the polls. But the new round of sexual allegations which the White House has denied May Handicap him. A it can to help but reduce his moral authority to govern a said Larry Sabato a political scandals expert at the University of Virginia in Charlottesville. A it has an effect particularly on people who oppose him. It tends to strengthen the opposition of those who Are not sympathetic to him in the first reflecting his narrow 43 percent Victory and activist presidency Clinton has had a High negative rating from the outset. Nearly one in four americans in a bipartisan poll conducted last month said e was performing poorly. A the hard Core negative is extremely High a said de Goeas the gop half of the polling team. A the president May be destined to be stuck with a 40 percent anti vote that is there through his entire some believe Clinton risks reinforcing his own negative image by glossing Over in at the expense and sacrifices required by his plans to Reform health welfare and government. A leadership consists of real Public education not Selling policies by big concepts like a Security a which Are not really representative of the Range of consequences that Clinton a proposals will entail a Stanley Renshon chairman of the political psychology department of the City University of new York graduate Center writes in the Spring 1994 Issue of the journal political psychology most Likely Clinton will continue having to fight for every Inch of Capitol Hill support and every percentage Point of approval. He is often congratulated for his resilience coming Back from near death in elections opinion polls and congressional votes repeatedly throughout his career. But Renshon said the real question is a Why does Clinton have so Many setbacks from which he has to recover a. C the associated press a a
