Focus: Washington: A new season for health reform

BMJ 1994; 309 doi: (Published 19 November 1994) Cite this as: BMJ 1994;309:1324
  1. J Roberts

    The health system that Congress refused to reform in 1994 has been largely responsible for the reformation of Congress in 1995. The past year's health debate contributed in at least two ways to the rout of the Democrats and the rise of the Republicans in this month's congressional elections.

    Firstly, the Democrats, despite holding a majority in the 1994 Congress, couldn't mobilise that majority to support even their No 1 priority - health reform. Secondly, and more importantly, the president became a liability. Bill Clinton was elected as a “new Democrat,” in support of the private sector and against big government. But his Health Security Act was seen as expanding the role of government. The Republicans successfully portrayed his plan as “an intrusion into the best health care system in the world.”

    Now the Republicans have to come up with something themselves. Both the new speaker of the house, Newt Gingrich of Georgia, and the Senate majority leader, Robert Dole of Kansas, have said they support previous Republican ideas to reform the health insurance system, though both want it kept private. They have said that Americans should be able to carry their insurance from job to job and that no one should be denied insurance because they are ill. They also support tax relief on savings designed to pay for later medical expenses. And both have supported to some degree better medical care for the poor. Nevertheless, “community rating,” the previously non-controversial idea that everyone pays nearly the same for insurance, appears dead. Mr Dole says it is unfair for the healthy young to pay for the elderly sick.

    One interesting result of the election was the addition of four doctors to the ranks of Congress. The most influential is Bill Frist, a multimillionaire cardiothoracic surgeon elected as Republican senator for Tennessee. Most of Mr Frist's money - including some of the $2m he spent on his campaign - comes from his family's business, the Hospital Corporation of America, one of the biggest for profit hospital chains in America. So far, he has remained silent on his plans for the health care system.

    Even though some health care reform is likely under the Republicans, the form it takes will probably not please the radical reformers. They will be equally disappointed if they look to the states.

    Californians, for example, soundly defeated a plan to create a single payer health system for California. Yet just two months ago the proposition was expected to pass easily. Apparently the voters' distrust of government reached down to state level. In fact, no state moved ahead with health reform with this year's election.

    One state, Oregon, did take a step in clinical care. By a small margin voters chose to allow doctors to hasten death for terminally ill patients. The new law will allow a patient with less than six months to live to ask a doctor to prescribe lethal drugs to end “unbearable suffering.” The patient must ask three times, at least once in writing. The patient must take the drugs, but doctors will be protected from criminal charges for prescribing scribing doses enough to kill. Oregon, pioneer of perhaps the most radical of reforms in its health rationing plan, also elected as governor the architect of that plan, John Kitzhaber. An emergency doctor and liberal Democrat, he stood against the trend toward Republican conservatism in 1994.

    Now that new governments and new governors are moving into new offices, America is taking a breather and wondering who - US government, state governments, or the private sector - will deliver health reform, and how.

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