NOW that the broad outline of President Clinton's health-care plan has emerged, it is important to understand what sorts of obstacles, roadblocks and potholes the plan will encounter as it wends through Congress.
The easiest way to get a handle on what lies in store is to take a peek behind the veil that was draped around the process by which the plan was born.
From February to May, I served as one of the 500-plus members of the Domestic Health Care Task Force advising Hillary Clinton on health-care changes.
Don't get me wrong -- I am hardly the quintessential political insider. I went to Washington leaning toward a single-payer, Canadian-style plan as best for this country. I left strongly convinced that some form of government-sponsored, state-administered single-payer system is the best way to provide universal coverage for a basic package of services at an affordable price to every American.
Since that was not the way the president wanted to go, I was assured a place in the far distant corner of the room when anything important was being discussed. By January, the president, his wife and their key advisers already had decided that managed competition was going to be the basic idea behind health-care change.
Managed competition contains costs by encouraging large groups of consumers to buy their health services from provider networks, what the plan calls "accredited health plans," that are run by private companies. These plans are to compete with each other on price, not coverage.
Universal coverage is to be obtained by subsidies that allow the uninsured to buy coverage directly or to small businesses, which are mandated to cover their employees.
Because this approach preserves enough of the free market to )) satisfy conservatives but guarantees a sufficiently adequate package of basic services at an affordable price to appeal to liberals, it was considered the only politically feasible one. But it left innumerable details.
One that was especially revealing was what would happen to existing health-care programs.
The patchwork of programs and insurance schemes that we have created since the end of World War II has built powerful constituencies that will work as hard as they can to derail any effort they see as threatening their vested interests.
Two examples of raw self-interest will give you a feel for the politics that the plan is up against.
One day I wandered into a meeting to talk about the future of the Veterans Administration health-care system under the changes.
Few in the room seemed to be listening as a VA official spoke quietly, but what he said was worth heeding. The VA system, he said, is the biggest government-sponsored health-care system in the world. It has a bigger budget than the entire British National Health Service. There is delicious irony in the fact that Congress, the U.S. military and its veterans all get their health care from a single-payer system.
He went on to note that the VA has a large and powerful political constituency with enormous clout in Congress. He stopped, but to those who had stayed awake an unstated message hung in the room: If in changing the health-care system you try to fool around with the VA, you will pay an enormous political price.
On another occasion I was talking to a woman who had worked for many years in the Indian Health Service. American Indians are entitled to use the IHS for their health-care needs. I wondered why there would be a need for the IHS if under the emerging health plan basic coverage would be extended to all Americans.
She was a bit startled by this question, but quickly went on to point out that in some parts of the country the IHS is involved in sanitation, sewage and many other programs in the Indian community.
Who would do these things if the IHS were abolished? Again, the message was clear: Don't touch our program.
Medicaid, Medicare, the Indian Health Service, the End-Stage Renal Dialysis Program, the Public Health Service, health coverage provided through workman's compensation and automobile insurance, the huge number of self-insurance programs used by many large corporations and unions -- each of these is a potential pothole for health-care change.
The other important insight I gained about the perils of trying to change a trillion-dollar sector of the national economy came not in Washington, but from my mail and fax machine when I returned home each week from task force meetings.
A mountain of communications was on my desk from every interest group you can imagine: chiropractors, speech therapists, psychologists, health club operators, public health nurses, herbal healers, dentists, pharmacists, chemical dependency specialists, nursing home operators, cosmetic surgeons. Professional associations, PACs and lobbyists suddenly felt the need to remind me that their constituents provide vital health-care services.
It will prove very difficult to cut the fat out of a bloated and inefficient system when every provider plans to fight as hard as ++ possible to stay on your payroll.
Still, one hopeful impression remains. The task force met in the Old Executive Office Building next to the West Wing of the White House. It is a big building with long corridors. Every day as I went into the building I passed bin after bin overflowing with mail. One entire floor of the building was bursting with letters from ordinary Americans who had written to Bill or Hillary to express their frustrations and hopes about health care.
Every one of those letters got read. They are part of the reason that mental health care coverage has not disappeared completely from the proposed plan, why there is still a chance that consumers might sit alongside professionals on the proposed new National Health Board and regional regulatory agencies or health alliances, and why there is still a chance that those who want to convince you to join their health plan might have to provide you with real information about the quality of care they provide.
The most powerful weapon you have to combat the huge vested interests who do not want to let go of their share of the trillion dollars the nation now spends on health care is a 29-cent stamp.
Arthur Caplan is the director of the Center for Biomedical Ethics at the University of Minnesota.