In a series of television ads sponsored by the Health Insurance Association of America (HIAA), Harry and Louise sit at the kitchen table discussing health reform. The ads are unremarkable, yet they have drawn the wrath of President and Mrs. Clinton. "It's time we stood up and said we're tired of insurance companies running our health care system," Hillary Clinton declared. Ira Magaziner termed the ads "unconscionable." Even some of the association's own insurance-company members took offense. New York Life called for a moratorium on the ads, and in the scuffle, Prudential became the fifth major insurer to pull out of HIAA.
The poverty line is a stock figure of American statistical and political culture. Most of us are at least dimly aware that it is an official level of income used to separate the poor from the non-poor, that the government somehow sets it, that it changes from time to time, and that it is the topic of periodic political fights. Even those who know its arcane details, however, usually forget that our official measure of poverty was once crafted by a real person with a passion and a pencil.
After a generation of deadlock, there is finally a broad consensus that the health system is broken, and a rare political opportunity to fix it. The present system manages to be simultaneously inflationalry, arbitrary, cumbersome for providers, and unreliable for consumers. But despite the opportunity for reform, we are on the verge of a disasterous mistake. Increasingly, it appears that the Clinton administration will embrace some variant of "managed competition." The strategy seeks to achieve universal converage and cost containment while simultaneously avoiding either public financing of the entire scheme or a bruising political confrontation with the health-industrial complex.
Once when I was about nine, I wandered into my aunt's kitchen during Thanksgiving to find all the grown-up women whispering, hugging, and crying. When they explained to me what was going on (Auntie Cookie had just found out she was going to have another baby and they were crying from happiness), they confirmed a story I already knew--the one about how babies just happen, and women to whom they happen are considered very lucky. How else to explain the crying? A few years later, when my friend Phyllis told me her parents were "trying to make" another baby, I had the crashing revelation that human actions create babies.
Marcus Welby was a myth; doctors have always cared about money. But the for-profit managed care industry makes no pretense: It's offering physicians money to make decisions that are plainly not in the interests of patients.
EDITOR'S NOTE: This article draws on material that will appear in more extended form as "The Doctor as Businessman: Changing Politics of a Cultural Icon," Journal of Health Politics, Policy and Law, vol. 22, no. 2, 1997.