or the second time in a decade, Americans are being asked to think clearly about expanding the health insurance system. First it was Bill Clinton, now Bill Bradley. There are two big differences between now and then.
Instead of the yawning deficits of the early 1990s, a tidy surplus is forecast for years to come, some portion of which could finance a reform.
And instead of Ira Magaziner at the drawing board, it is a coterie of health care economists, policy experts, and clinicians who have prepared the far more modest plan espoused by the former New Jersey senator.
Typical of them is Alan Garber, a PhD economist (Harvard) and a physician (Stanford). As much as anyone, he exemplifies how things have changed in health care economics since the early 1990s.
It isn't easy to call to mind the implausible episode that unfolded when, five days after his inauguration, Bill Clinton put his wife in charge of the National Health Care Reform Task Force in 1993 with orders to deliver sweeping legislation to Congress in 100 days.
Hillary Rodham Clinton promptly hired old family friend Magaziner as staff coordinator, and he orchestrated a series of supersecret deliberations in the manner he had learned during his brief tenure as a corporate consultant.
The escapade ended with the Republican landslide of 1994, when the Democrats lost control of the House of Representatives for the first time in 40 years. The GOP began its even more implausible impeachment quest, and Magaziner's 3,000-page plan promptly was forgotten.
Until about six weeks ago.
Then, calling access to health care insurance ''an American birthright,'' former senator Bradley proposed expanding the system to include most of the 45 million Americans currently without health insurance - especially 11 million or so children.
How? Says Garber, ''Senator Bradley asked a group of us last winter how to go about reducing the number of uninsured right away. And all of us were thinking the same thing: something like, expand the Federal Employees Health Benefits Program.''
What's FEHBP? Nearly half the people in Washington are covered by its insurance, making it the largest benefit plan of its sort in the nation. It functions a little differently than the medical benefits office of a large corporation.
The government pays some portion of the annual premium - around 70 percent is the average - and employees pay the rest, depending on the depth of benefits and the size of the deductible.
Federal workers around the nation choose among about 300 different plans - health maintenance organizations, preferred provider organizations, and the like - on the basis of quality and price. Once a year they are free to shop around. The competition among the plans for their business makes the system work.
The plan proposed by Bradley would permit currently uninsured Americans to buy into the existing FEHBP system. It would subsidize the premiums of those who couldn't otherwise afford it, from a full ride for the really poor to partial subsidies for children in households earning up to $49,200.
Bradley estimated that the plan would cost about $65 billion a year by the time it was fully in place, requiring about 70 percent of the federal surplus that is not related to Social Security, and resulting in about 95 percent of all Americans being fully insured.
Vice President Al Gore immediately disparaged Bradley's plan, on grounds that it would cost too much. ''Costs are never entirely predictable,'' says Garber, ''but the costs of this plan are much more predictable than those of any other plan involving more fundamental change in health care financing.'' It is, above all else, he says, a pragmatic plan.
''We're taking a system that works reasonably well and adding to it. We're not claiming that it works perfectly. But we're not talking about inventing something new.'' One worry: whether little firms will fold their plans once government-sponsored insurance becomes available.
So who is Alan Garber? He is the currently visible tip of a new and thriving community of health care economists. As Victor Fuchs of Stanford University has noted (he is the dean of the field), there has been a worldwide expansion of health economics in the past 35 years. The number of PhDs awarded annually in the United States has increased 12-fold since 1965.
Left, right, and center, it is now possible to hold a disciplined conversation about topics that were barely understood when the federal governmemnt lurched into health care in a big way with the beginnings of Medicare and Medicaid in 1965.
Garber arrived at Harvard College in the fall of 1973. Among his classmates were Bill Gates and Steve Ballmer, who went on to found Microsoft. Down the street at Massachusetts Institute of Technology was Lawrence Summers, now secretary of the Treasury. Labor economist Richard Freeman trained Garber; econometrician Zvi Griliches persuaded him that he could do the coursework for a PhD in economics in a single year before entering medical school at Stanford. (He roomed with Harvard's Jeffrey Sachs.)
So Garber worked as a research assistant for economist Kenneth Arrow while pursuing his medical studies at Stanford, writing his dissertation under the supervision of a committee headed by Harvard's Martin Feldstein. He met his future wife when both were residents at Brigham and Women's Hospital in Boston, before they returned to Stanford. (Trained as an oncologist, she now works as medical director of a hospice.) Two years ago, Garber almost returned to the Brigham as chief of general medicine.
''There is plenty of room for pure PhDs who never go near a hospital,'' says Garber, ''but those of us who have MDs do see things a little differently. I don't know what it's like to be a private-practice doc, and I don't know what it's like to be a surgeon - I'm a general internist - but I still get there in the trenches, in a limited way.
''I still make rounds when ward attending. You get to see... what some of these policies mean at the level of the patient and the practicing physician: what it means, for instance, to be limited to 10 or 12 minutes for an office visit; what it means to comply with Medicare documentation requirements. Not every health care economist needs to be sensitized to these issues, but somebody should be.''
No sooner did Bradley propound his plan on Sept. 28 than Feldstein attacked it, though it had been devised in part by his former student. There were three problems, Feldstein wrote, in a piece on the editorial page of The Wall Street Journal. It would require a ''massive'' tax increase, do relatively little to reduce the ranks of the uninsured, and significantly worsen the quality of health care for most Americans. Garber equally quickly disagreed.
Feldstein serves as an adviser to Republican candidate George W. Bush. He advised George Bush the president as well, and Ronald Reagan before him. He went out of his way to link the Bradley plan with the Clinton plan. It ''suffers from many of the same defects,'' he wrote.
In fact, it could hardly be more different. The fundamental philosophical difference is that the Bradley plan makes no attempt to define the components of a basic plan. There is nothing in it about mammograms and mental health benefits. Those decisions are left to the marketplace, where individuals remain free to make their own decisions about price and quality, as they do now, with one plan competing against another.
It is possible to oppose Bradley's plan on principled grounds. Feldstein may think the surplus is not really there. Or he may prefer medical savings accounts, tax-sheltered savings of a sort favored by some Republicans. Or he may simply think it not worth bothering with those 10 million children. ''This big step along the road to a welfare state is not, to put it mildly, what America needs,'' he wrote.
Let the debate begin!
