3 July 2012

Remembering Hillarycare

Filed under: Culture, Reflections — ktismatics @ 7:03 am

In 1993, during the first year of Bill Clinton’s first term, Hillary came under fire for attempting to engineer Hillarycare. In many ways it was like Obamacare: a federally mandated program for universalizing private-sector healthcare. It was decidedly more aggressive on the public administration side, however. The idea was roughly this:

Individual mandate: Everyone would be required to enroll in a federally-approved healthcare plan.

Employer mandate: Every employer would be required to provide an approved healthcare plan for all of its full-time employees.

Universal coverage: Those who weren’t full-time employees and who couldn’t afford to pay for a health plan would be subsidized up to 100%, funded via tax revenues.

Integrated care: All approved plans would combine the functions of the insurer, the doctors, and the hospitals. This vertically-integrated care model was characteristic of private-sector health maintenance organizations (HMOs), which since their origins during the Nixon administration had achieved demonstrably more effective care with lower costs than the traditional model of insurers contracting separately with doctors and hospitals. Enrollees in integrated care systems would prepay a monthly fee covering all of their care, rather than paying piecemeal fees for specific services rendered. Under this arrangement much of the risk for unnecessary overutilization of services and escalating cost is transferred from the payer to the integrated care system.

Public option: Everyone would be eligible to participate in the Federal Employees’ Health Plan. This plan was widely recognized as achieving exemplary cost-effectiveness and member satisfaction in providing comprehensive care for a large cohort of enrollees. The FEHP already operated on a national scale according to the proposed model of contracting with private-sector integrated delivery systems, so it would serve as an exemplar, as well as the toughest competitor, for private-sector systems as they ramped up.

Managed competition: Each approved plan would be required to offer its enrollees a minimum package of coverages with minimum out-of-pocket charges. Because most people use healthcare services only sporadically, it’s notoriously difficult for them to evaluate the quality of care they receive. Also, under the HMO-style prepayment scheme, integrated care systems might be tempted to scrimp on necessary care in order to save money. Therefore healthplans would be evaluated based on aggregate statistics according to measured health outcomes, appropriateness of care, and adherence to evidence-based clinical best practices. Underperforming plans would be penalized financially or, for serious continual failure, disapproved.

Generally supported by Democrats and physicians, Hillarycare was widely renounced by Republicans, health insurers, and the pharmaceutical industry. The main counter-arguments, presented repeatedly by the opposition in TV ads, were that the plan’s bureaucracy was unwieldy and that it would result in inhumane rationing of healthcare services. These accusations were patently false, as evidenced by the demonstrable success and popularity of the Federal Employees’ Health Plan. The real concern, of course, was that the combination of the employer mandate, prepayment replacing fee-for-service, an attractive public option, and managed competition would restrict profitability in the private sector.

Eventually the Democrats in Congress began to fold under pressure, and Hillarycare died in committee on Capitol Hill. (Personal note: I was called to testify at a Hillarycare committee hearing in DC, focusing specifically on the “managed competition” component of the proposed legislation.) Vertically integrated care, at the time an up-and-coming model, has largely gone away, replaced by the fragmented redundancies and gaps and multiple profit-taking sectors of an earlier era. When Hillary ran for President she didn’t try to bring her old plan out of mothballs. Instead she, like Obama, adopted the variant of Romney’s Massachusetts plan that is now enshrined as Obamacare.



  1. ” I was called to testify at a Hillarycare committee hearing in DC, focusing specifically on the “managed competition” component ”

    In what capacity? Pardon me asking ( I haven’t followed this blog closely, and there’s no little ‘about’ box at the top – quite inscrutable), but what do you DO, John? For a while I assumed you were a tenured academic – English or philosophy or…. but then you described yourself as self-employed (I think)


    Comment by lafayettesennacherib — 5 July 2012 @ 3:23 am

  2. For awhile I worked in a healthcare think tank, during which time I managed a national demonstration project involving most of the big health insurers and many large employers (GM, GE, etc.). The purpose of this project was to pool and analyze health outcomes data in an attempt to compare health plans with targets and with each other. The project had pretty high visibility, and my boss at the think tank was well-connected in governmental circles. Consequently I was called to testify in part about this private-sector initiative, as well as to describe the consulting work I was doing at the time, focusing on similar outcomes evaluation projects for large corporate clients. The intent was to demonstrate proof of concept for the “managed competition” component of Hillarycare.

    I studied psychology, which in its empirical core is predicated on the ability to collect data and to conduct statistical analyses. English or philosophy? The only English elective class I took in college I failed. It was a poetry class, the entire grade being based on an essay about Ginsberg’s Howl. But the antiwar protests were raging and I just had no inclination to write the essay. I took some intellectual history but no philosophy.


    Comment by ktismatics — 5 July 2012 @ 6:25 am

  3. Ah, psychology! That’s what you write about most – hard to spot. About half of the content of my first degree was in psychology. I gently chide Dejan over his Freud and Lacan bit, but I suppose like most people back then (early 70s) and probably still, that’s the sort of thing I expected of a psychology course, and was bored with the reality of painstaking experimentation to try and establish some little facts as building blocks for the science. So I just did the minimum, read it up for the exams and forgot it the next day.

    Your writings on psychology are interesting but mostly above my head – I just haven’t done the reading. Still, occasionally my thoughts turn that way. Apart from Max Velmans’ book, I got hold of last year Eric R. Kandel’s ‘In Search of Memory’, and a couple of other books on memory by Eysenck and Baddeley. Do you know Kandel’s book? Do you rate it?

    Kandel published a new book last month, which looks fascinating : ‘ The Age of Insight: The Quest to Understand the Unconscious in Art, Mind, and Brain, from Vienna 1900 to the Present’.


    Comment by lafayettesennacherib — 5 July 2012 @ 10:23 am

  4. I’ve not read anything by Kandel, but I see there’s a copy at my local library branch so I’ll pick it up.. You mentioned Velmans’ book on consciousness when I posted on another book about the history of the unconscious — I just requested it from the interlibrary so I can have a look. I’m between nonfictions, having read the first 3 chapters of Pinkers’ long new book about the historical decline of violence. I’m not persuaded by his argument and I doubt I’ll read the rest, but I might post something about it before returning it to the library.


    Comment by ktismatics — 5 July 2012 @ 1:25 pm

  5. I’m already skeptical of Kandel and here’s why — from the first paragraph:

    “You can recall your first day in high school, your first date, your first love. In so doing you are not only recalling the event, you are also experiencing the atmosphere in which it occurred — the sights, sounds, and smells, the social setting, the time of day, the conversations, the emotional tone.”

    Not only do I not re-experience the atmosphere: I don’t remember anything at all about my first day in high school or my first date. Anyone who can remember such things must have a brain that’s different in significant ways from my own. Flicking through the first couple of chapters I see that, if I actually read this book, I’m going to be subjected to many of Kandel’s detailed memories. I will no doubt forget them almost immediately, especially since I have no a priori interest in this man. If he actually writes anything about the substance of his memory research then I’m more likely to remember that material, my semantic memory being much better than my episodic memory. But I’d have to read it before I can possibly remember it, and I’m not yet committed to the endeavor.


    Comment by ktismatics — 5 July 2012 @ 11:43 pm

  6. I’ve got Kandel’s ‘in search of memory’, but I haven’t got round to it yet. I think it was Amazon reviews that persuaded me it was essential, but on looking at the Amazon pages again I felt a growing skepticism myself. I’m skeptical about Nobel prizes for a start – Hannes Alfven (electrical engineer – google him) I can believe, but when it comes to the more nebulous areas…? And (is it ok to say this here) the reviews of his new book seem to suggest a distinct ‘ethnic particularism’ in the stories he focuses on; and (maybe this is the reviewer, not Kandel, but the presence of Freud (unless very qualified) seems to fit into a pattern.

    Still, I gather it’s for a popular audience, not a textbook, so … I’ll get round to it one day.

    Velmans’ book IS an academic texbook, a survey of ‘the state of things’ in consciousness studies, plus an original contribution and philosophical work. But it is also really, really readable – as readable as any populist work, but more so because it’s the real thing.


    Comment by lafayettesennacherib — 6 July 2012 @ 7:14 am

  7. I DO remember my first day in high school – at least a couple of items stand out. I even remember my first day in primary (elementary?) school at age six very vividly.


    Comment by lafayettesennacherib — 6 July 2012 @ 7:17 am

  8. “I see it as corruption,” he said. “I think it is horrible.”

    Yet more evidence of greedy physician bastards, again allying with pharma against patients and payers to rake in yet more dough.


    Comment by ktismatics — 11 July 2012 @ 10:59 am

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