Ever since the Clinton health-care reform was unveiled 11 months and a dozen plans ago, it has been dogged by an obvious contradiction: It promised both universal coverage and control of exploding health-care costs, now 14 percent of American gross domestic product.
It was clear and much remarked that expanding coverage to 37 million now-uninsured Americans, by increasing demand, would substantially raise health-care costs.More care means more cost. That is obvious. But there is a another, less obvious and quite perverse contradiction buried at the heart of the health-care debate: Better care makes for more cost, too.
The ordinary progress of modern medicine - quite apart from the cost of high-tech machines and tests and procedures - makes health care more and more of a fiscal drain.
"It is often difficult for lay people to appreciate that good medicine does not reduce the percentage of people with illnesses," writes physician-philosopher Willard Gaylin in a brilliant critique of the health-care debate (Harper's Oct. 1993). "It increases that percentage."
Good medicine keeps sick people alive, people with heart disease, diabetes, hypertension and other chronic diseases. And sick people are expensive. The dead are a burden to no one.
Even preventive medicine, that sacred health-care cow, increases costs, points out Gaylin.
Diphtheria and whooping cough, once the two leading causes of childhood death, have ceased to exist. "But they were rarely expensive. The child either lived or died and, for the most part, did so quickly and cheaply." Now that child "will grow up to be a very expensive old man or woman."
Because of these hard truths, the great health-care debate of '94 will turn out to have been both preliminary and peripheral.
Consider: Among the welter of disagreements now highlighted in the Senate debate, there is a clear national consensus for some reforms. Even the Dole plan mandates that health-care insurance be portable (you retain it when you change jobs) and accessible (you cannot be denied it for a pre-existing condition).
Inevitably, however, such guarantees must increase health-care costs. If the currently screened or dropped out are to be included and cared for, someone will have to pay for their care. There is no free lunch. Either insurance premiums go up or taxes go up or business pays through "employer man-dates."
In the end, there is no way out of the dilemma: Both extending health-care coverage and improving health-care quality will increase health-care costs. We must pay for that cost by pushing yet higher health care's share of GDP.
Or we must ration.
No one, of course, dares speak the word. There is not a politician who does not recoil from it. But after this debate, we will have the rationing debate.
Having boosted medical costs even beyond the bank-breaking level of today, we will have to begin deciding which people with which diseases at which ages will be denied the public provision of which medical procedures.
Others have done it and so will we. In Britain, if your kidneys fail and you are over 55, you are routinely denied life-saving dialysis by the National Health Service. If you cannot afford private insurance or the out-of-pocket expense, chances are you die.
Even the Clinton plan had some rationing, though it had to be kept covert. It would, for example, have severely restricted the number of medical specialists.
This is indirect rationing. If you reduce by, say, one-third the number of people who can do brain surgery, then many people who need it and who now get it will not be able to.
The Clintons defended that measure, tellingly, not as rationing but as an effort to promote the currently fashionable primary care over "specialization."
No one is ready to talk now about rationing. That talk is too unpleasant, the tone too pinched, the vision too Carteresque.
Instead, the politicians are holding a picnic and giving away the food. The Democrats are offering "health care that cannot be taken away," a new fundamental right of, literally, untold cost. Even the limited Republican reforms would subsidize health care for over 35 million Americans.
That costs money. Where do we get it? Gaylin is right: When this round is over and we are quite through giving away what we cannot afford, the real health-care debate, the debate about rationing, will have to begin.
And if, like Hillary Clinton, you think Round 1 was nasty, just wait for Round 2.