Will Clinton’s Plan Be Fair?

Health Security Act

103d Congress, 1st Session
US Government Printing Office, 1,342 pp., $45.00 (paper)
Hillary Rodham Clinton
Hillary Rodham Clinton; drawing by David Levine


President Clinton’s Health Security Act is the most important piece of domestic legislation since the Civil Rights Acts, and because it is an attempt to reform one seventh of America’s economy, it could prove the most significant economic change since the New Deal. Though no congressional vote is expected for about a year, the act has already been comprehensively analyzed and debated by politicians, doctors’ associations, health-care economists, insurance companies, small and large business groups, and journalists. Very little attention has been given to the most profound issue it raises. How do we decide whether the Health Security Act, or any other structure for medical care in the United States, is fair?

Everyone agrees that the United States now spends too much on health care. Medical services accounted for 14 percent of our gross domestic product in 1991—France and Germany spent 9 percent and Japan and Britain 8 percent—and economists predict that without reform medical expenses would grow to 18 percent by the year 2000. But how much should a nation like ours spend on its citizens’ health? How do we know that other nations are not spending too little, rather than that we are spending too much?

Most people also agree that health care is unjustly distributed in America. Forty million Americans have grossly inadequate medical coverage, or none at all, and many who do have adequate insurance now will lose it, because they will lose their jobs or develop a disease or condition that makes them uninsurable. In all, without reform, a quarter of all Americans will be without health insurance for some period during the next five years. But how much health care should a decent society make available for everyone? We can’t provide everyone with the medical care that the richest among us can buy for themselves. How do we decide what lesser level of care justice demands even the poorest should have?

Clinton’s act is long and elaborate—1,342 pages and 240,000 words. I shall summarize its main features. It aims to achieve universal coverage by requiring every resident of the United States to participate in some form of health plan. To reduce overall costs it would require people not to negotiate directly with a plan as individuals, but to join a large purchasing cooperative (called a regional health-care “alliance”) which would use its size and bargaining power to secure the lowest possible rates for health-care coverage. Each alliance would enter into contracts with a variety of plans and would offer its members a choice among them.1 Under the Health Security Act, state governments must create these alliances by 1998, and each state has considerable leeway in deciding how many to create and what territory within the state each will administer.2

Alliances must enter into contracts with any state-certified health-care “plan”—whether it is sponsored by an organization of hospitals and doctors similar…

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