WILLIAM GRADISON: INSIGHTS INTO THE PAST AND FUTURE OF HEALTH CARE POLICY-MAKING

Remember Harry and Louise?

They were the middle-class couple that worried so much on television commercials about how the Clinton administration's health care reform package would destroy the health care system.

The couple was fictional, but their anxieties about the Clinton proposal in an advertising campaign paid for by the Health Insurance Assn. of America, an industry trade group, had much to do with increased public skepticism of the package and the eventual collapse of the plan.

A professional advertising agency created the Harry and Louise campaign after HIAA President Bill Gradison came up with the idea of a couple sitting down at a kitchen table, the place where families often talk through issues.

Reflecting three years after the demise of the Clinton plan, Mr. Gradison, 68, attributes the plan's failure to many administration mistakes, not the least of which was the administration's secrecy and its overreaching.

Mr. Gradison has considerable experience and success in developing a consensus.

Before joining the HIAA in 1993, he served 18 years as a Republican member of Congress, including as ranking minority member of the House Ways and Means Health Subcommittee. Widely respected for his moderation and political good judgment, Mr. Gradison helped develop and win passage of a wide variety of health care legislation, including COBRA's health care continuation provision.

Mr. Gradison discussed his views on a variety of health care issues with Editor-at-Large Jerry Geisel.

The year is 1992. Bill Clinton has been elected president. Were you hopeful or fearful of what the new administration would propose in the health care reform package that it said it would develop?

I didn't have any idea of what they would come up with. Health care reform was an issue -- responding to what was thought was public concern -- that the administration gave a high priority to.

But the process they set up to develop their plan made it very difficult from the outside to get a sense of what it might actually be.

Did you think you could work with the Clinton administration?

Absolutely.

All my Washington experience suggested that reasonable people can sit down and work things out. We attempted to do that. But in the end, it proved impossible because the administration decided it needed some villains in order to sell its plan.

Insurers were to be among the selected few. Saying that was not paranoia. It was reality. It was reflected in statements that came from the First Lady, among others.

When did you get a sense that the administration was not interested in working with the health insurance industry?

I had three meetings with Ira Magaziner, which were totally pleasant. He started the first meeting by saying something like, "Pollsters at the White House tell us that it will help us to sell our plan if we identify as enemies (of the plan), health insurers, the pharmaceutical manufacturers, and the physicians." The physicians later were dropped.

When did you decide that you had to take, if you will, a more aggressive, a more adversarial approach?

When the August 1993 recess of Congress came along, there was a paper developed for Democratic incumbents for when they went back to their districts. It was chock-full of inaccuracies and criticisms of our industry.

Our chairman then -- David Hurd of The Principal Financial Group -- went through and marked up a copy. I believe he identified 40 or 50 inaccuracies or unfairnesses in there. From then on, my counsel of "let's try to work with them" didn't carry much weight.

David took the lead in pressing us to develop a more aggressive stance, and also a fund-raising effort among members to finance an aggressive campaign.

It was a voluntary fund-raising campaign but an extraordinary success. I think that was partly a result of the industry reacting to unfair criticism and a reaction to Dave Hurd's leadership.

Harry and Louise -- that middle- class couple that had so many anxieties about the Clinton health care reform plan -- who came up with that?

The writing and selection of scripts was done by (advertising agency) Goddard-Claussen. The idea of a couple sitting down at a kitchen table talking about health insurance goes back to some speeches I gave before I ever thought of leaving the Congress.

What I said briefly was that health insurance was the only issue I knew of in the 30-odd years I held elective office that directly impacts on every American family.

Therefore, I concluded, it would not be decided by advertising or speeches, but to quote myself, over the kitchen tables of Americans as they sat down and asked what this meant to them and their families.

Mrs. Clinton made no secret of her distaste for the advertising campaign. Did that surprise you?

Yes, it did, because of the way it helped to get our message across.

I have been in politics a long time. One of the things I have learned is not to give attention to your critics.

We didn't buy any time from the three major networks. After her explicit criticisms made our ads news, the networks, in their newscasts, showed our commercials and her criticism of them together.

We ended up getting an enormous amount of free exposure to our ads in network news.

From a standpoint of Politics 101, her criticisms of the ads were puzzling to me and, frankly, they still are.

In short, she gave you priceless publicity?

We didn't have the money to buy it.

Why did the public respond so favorably to the ads?

People could relate to them (Harry and Louise) as individuals.

Why did the Clinton health care reform plan die? What were some of the factors?

The main thing is that while the public then and now is not satisfied with the health care system, they want changes to be done in a step-by-step way.

One of the realities of health insurance that makes it so difficult to bring about a change is its very success. About 85% of Americans have health insurance of one kind or another. That is not good enough. But it means that a lot of people are cautious about swapping the known for the unknown. The Clinton plan really didn't leave alone those who are covered and are satisfied.

This is a country that moves gradually when dealing with problems.

Does that explain why the limited health care portability legislation passed last year even though comprehensive reform legislation died in 1994?

Yes, and that is why in 1997 there was further progress made in coverage through the children's health care initiative in particular. A step-by-step approach may prove a quicker way of getting there.

What effect will the health care portability measure have on increasing access to coverage?

I think it will increase accessibility and decrease affordability.

When there is a trade-off -- both at the federal and state levels -- between access and cost, there is a tendency to go for access. But I don't think in the group market that the Kassebaum-Kennedy legislation will have much effect one way or another on costs. The hazards are in the much smaller and fragile individual market.

This whole question of access vs. affordability is reflected in the discussion of benefit mandates as well at both the state and federal levels.

The key is understanding there are some costs involved. What is so difficult from a public policy point of view is that we have a voluntary system. If the price of health insurance seems too high to businesses or individuals, then they don't buy it.

Is that where we are going -- legislation, so to speak, by body part? We've seen mental health care benefits parity, mandated minimum inpatient coverage for mothers and newborns after delivery? What's next?

It is too early to tell. Certainly, the initial steps that were taken as far as maternity stays and the modest step taken with regard to mental health stays were very hard to vote against. I think there have been some second thoughts.

Once the idea of a mandate is accepted, it is very hard to say there should be a mandate for maternity but there shouldn't be for mastectomies or other benefit coverages.

Has partisanship changed in Congress?

You worked with Rep. Pete Stark, D-Calif., to get COBRA's health care continuation provisions enacted in the mid-1980s. Is it more partisan today, or does Congress act in a more bipartisan way compared with the 1994 period?

Things do seem more partisan overall. But within the Ways and Means Health Subcommittee, I can't tell you how excited I am by the bipartisanship that has developed there.

Pete Stark and Rep. Bill Thomas, R-Calif., are working in the same way that Pete Stark and Bill Gradison worked when the tables were turned, when Pete was the chairman of the subcommittee. That bipartisanship was reflected in the wide range of health care issues that came to the committee earlier this year.

To what do you attribute that unanimity after so much dissension?

I expect these two fellows and their staffs came together and tried to work together much as we used to come together and work things out.

You know you can't really spring things on people and expect them to participate enthusiastically.

One of the greatest critics of the process that led to the collapse of the Clinton health care reform plan was Pete Stark. He felt very much frozen out of the process and he was chairman of one of the subcommittees that had to move the legislation at that time.

It is not the way to get a buy-in when you are trying to move legislation.

What are your concerns about the future?

The key to successful incremental change is to put money on the table; i.e., to recognize the desirable goal of greater coverage cannot be accomplished by shifting costs to those who already are covered.

That is not just a political comment. It also is an economic comment. Pushing up costs of insurance for the currently covered as a means of paying for the uncovered runs the risks of people dropping out entirely.

Your last thought?

The greatest challenges facing insurers and health plans are not a result of regulatory or legislative changes at the state or federal levels in most cases.

In fact, the really dramatic changes are in the marketplace. They are accelerating. I think it is virtually impossible to tell what these plans are going to look like in just three to five years.

It wasn't so long ago that some people thought health maintenance organizations would carry the field. We now are finding that traditional HMOs with limited networks are not where growth is. It is plans with greater choice.

Regrettably, greater choice involves greater cost. How that trade-off is resolved will have a lot to do with determining what options are available in the private insurance markets.