Theodore Marmor, Ph.D. responds to Uwe Reinhardt, Ph.D., and suggests the federalist option for health care reform:
I have looked over not only your comments to me, Uwe, but also the exchanges with others. Can we proceed this way? I have enclosed a long essay on reform in American medicine that takes up many of the issues you raise (1). It is not as if it were written with you in mind, but this chapter represents the distillation of my thinking about such matters. I would regard this as one step in our understanding each other. Another would be for me to acknowledge that I have felt as much frustration as anyone in connection with American medical politics. I sometimes think of emigrating--to Canada, to Britain, to Australia--to escape much of the misery of our public debate on matters like universal coverage, managed care and the like. But my analysis of why we face what we do differs substantially from yours, and this essay--along with another on managed care--should make it plain (2). These essays are simply more considered presentations than I could make on the run, just as I am off to Alaska to fish for salmon and then on to the political science meetings in San Francisco.
My hope would be that you might look at these papers and, if you have the time and inclination, look at either Larry Jacobs and Robert Shapiro's new book, Politicians Don't Pander, (Chicago U.P., 2000) or any of the books by Ben Page. These are more considered treatments of American public opinion than anything available in Health Affairs. When I get back--the 5th of September--I will take up the particular questions about medical reform politics you raised in the letter to me. They are good questions and I think I have responses that will make some sense to you. To foreshadow my views, just consider what would have happened in l992 if the election of Bill Clinton was at the same time an election of a majority in both houses of Congress for a type of universal coverage. In the US the question of whether, what, and when get conflated and mixed up more than in other institutional settings. And, as you will see in the Next Agenda piece, we think that is fateful, not the level of American other directedness.
Looking forward to getting back to this in early September.
Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management
(1) Jonathan Oberlander and Theodore Marmor, "The Path to Universal Health Care," from "The Next Agenda: Blueprint for a New Progressive Movement," Robert Borosage and Roger Hickey, editors, Westview Press, 2001.
(2) Jacob Hacker and Theodore Marmor, "How Not to Think about 'Managed Care'," University of Michigan Journal of Law Reform, Volume 32, Issue 4, Summer 1999.
Note: Dr. Marmor has made both of these documents available in Microsoft Word format. If you would like to receive either one, or both, please reply to this message with a request specifying (1), (2), or both.
Comment: Quoting from reference (1): "Under (the federalist) option, national legislation would be passed that encourages the states to enact universal coverage, insurance reform, and cost control, but gives the states choice over what types of reform they wish to implement." "The federalist strategy, referred to by others as a state-federal partnership, offers the prospect of genuine health reform and he advantages of political flexibility." "We recognize that embracing the federalist option would mean altering the past emphasis of American reformers on enacting the Canadian single payer model. That would by no means be an easy transformation or compromise to make."
Under the federalist option, the states would still be required to enact reforms that guarantee universal coverage, comprehensive benefits, administrative accountability, fiscal viability, and portability. The sharp contrast from single payer proposals is that public administration would not be mandated, allowing any form of administration, including the current competing market plans. Abandonment of the economies and efficiencies of public administration, not to mention the assurance of equity, seems like an unacceptably high price to pay for political expediency, at least in my opinion.
Don