A mere six months ago, Big Tobacco stood astride the American political scene, the colossus of evil. Every public interest group despised it. Every Democratic politician railed against it. Its public approval ratings trailed Linda Tripp's. Its political contributions were tainted. But then something funny happened on the way to the ballot box: Democrats found themselves a new boogeyman to replace the tobacco barons. The Dems' new "merchants of death": health maintenance organization bureaucrats.
The 1998 campaign's vilification of HMOs marks the culmination of a remarkable and speedy collapse of the industry's image. Just five years ago, HMOs were the golden children of the busted health-care industry, imposing the cost controls and efficiencies everyone agreed the system needed. But during this summer and fall, Democratic candidates have had a field day telling HMO horror stories. HMO has become a synonym for heartlessness and windfall profit, and political contributions by health insurers are blood money.
In the Missouri senate race, for example, a Democratic TV ad declared that Republican incumbent Kit Bond would let "insurance company bureaucrats make your medical decisions" because he had accepted $200,000 from the insurance industry. An ad tarred Illinois' Republican gubernatorial candidate George Ryan for accepting contributions from "exactly those HMOs that are charging us more while providing us less." Arizona Democrat Paul Johnson ran ads saying that incumbent Republican Gov. Jane Hull "has taken tens of thousands of dollars from HMOs and big insurance companies and then steadfastly refused to impose any meaningful reforms on an industry that is clearly out of control." In North Carolina, Georgia, Wisconsin, Kentucky, Texas, Florida, Ohio, and elsewhere, Democrats have anchored their campaigns to HMO reform and depicted opponents as shills for the health insurance industry. The issue is the key to "almost every race I'm involved in," says one Democratic pollster.
As a purely political matter, health insurance populism seems all upside for Democrats. Americans always worry about health care, and they are especially fretful about managed care. HMOs have new rules that they have not adjusted to and don't much like, and the industry has its share of profiteering shysters. HMOs are still an experiment: Americans have not yet decided if we like having for-profit corporations controlling our medical care.
The pop culture, a leading political indicator, is full of HMO bashing. Audiences at last year's movie As Good as It Gets burst into applause at the line--voiced by the mother of a sick child--"Fucking HMO bastards! Pieces of shit!" HMO horror stories have spread widely and rapidly: "drive-through" baby deliveries, the experimental chemotherapy denied to a child with cancer, the accountant who proposed permitting cataract patients to have surgery on only one eye because you need only one eye to see. (Consumers for Quality Care, an anti-HMO group, even picks an HMO "Casualty of the Day.")
All this is fertile soil for Democrats. Republicans in the Senate, after all, did just kill a (relatively modest) HMO reform bill. Republicans are in the pockets of the HMO and insurance industries. (Senate Majority Leader Trent Lott's office told health insurance executives to "get off your wallets." And they did, forking over millions to the GOP this election cycle.) And Democrats' proposed reforms are not elaborate and not unreasonable: the right to sue your HMO, the right to appeal denial of treatment, no gag rules for doctors, and easier emergency room access. One survey showed that 90 percent of Americans support such changes, and 85 percent would favor a candidate who supports them.
(Democratic HMO bashing is also an unexpected windfall from the defeat of Clinton's 1993 health plan. Under the Clinton plan there would have been tacit rationing, limits on service, and more rules about doctor visits--exactly the kind of bureaucratization and handcuffing of doctors that Americans so deplore in HMOs. Killing the plan has backfired on the GOP. Had Republicans let Clinton's plan go forward, they would now be the ones campaigning against bureaucratic medicine and telling nightmares about Clinton Care. Instead, managed care went private, the Democrats get to inveigh against it, and the Republicans are absorbing all the blame.)
Despite its political logic, this vilification of HMOs is a dismaying manifestation of two common illnesses of American politics. The first is Something-for-Nothingism. Democrats have seized the HMO issue this fall because it is classic entitlement politics. Americans are understandably ambivalent about health insurance. When your child gets sick, you naturally despise the frugality that made your HMO so attractive when you subscribed. Americans want--no, expect--health care to be both infinite and cheap. We should have everything, paid for by someone else who shall remain nameless. Democrats, by pushing regulation without acknowledging its costs, are feeding this impossible expectation. (Something-for-Nothingism is, of course, the guiding philosophy of almost all politics. There is no reason health care should be an exception.)
A principled Republican response to the Democratic anti-HMO campaign--and a response that a few Republicans are actually making--is to say: "OK, if you want to have the right to sue your HMO, you are going to have accept x percent higher premiums and that's going to price y thousand customers out of the health insurance market." But most Republicans, who are as willing to pander as the next guy (heck, more willing), are afraid to fight on the merits. Instead, they are countering one boogeyman with another, claiming that voters should reject anti-HMO Dems because they are beholden to trial lawyers. This is too bad, because a fight on the merits is exactly the way Americans could make an informed decision about how much HMO regulation they want.
The anti-HMO strategy is also evidence of the pernicious influence of Anecdotal Politics. The benefits of managed care are unremarkable and undramatic (lower premiums, more preventive care). But its costs are visible and awful (denial of and delays in care). The result: Democratic candidates have terrible tales to tell, and Republicans have nothing to reply with.
A 1997 Henry J. Kaiser Family Foundation survey found that Americans in managed care plans are basically content with their own care. But they are more worried about the future than those in fee-for-service plans. Why? Largely because they have heard so many alarming tales about HMOs. Never mind that no hard evidence exists that American health care has actually deteriorated under managed care.
This is why managed care is a genuinely confusing issue: Should voters believe the anecdotes, which are real and horrifying, or should they accept the evidence that people are mostly happy with their own insurance, happy to be paying less, and as healthy as they have ever been? Both parties in the '98 campaign offer an easy answer to that question. The difficulty for voters is that neither answer is completely right and neither is completely wrong.