Health reform for the 21st century? It may have to wait until the 21st century

To assess the likelihood of health care legislation in the forthcoming 105th Congress in 5 areas: health care coverage, tax and Employee Retirement Income Security Act (ERISA) policy, Medicaid, Medicare, and managed care.

Informal, semistructured conversations that took place in the months prior to the 1996 elections.

Congressional health staff and administration officials.

Unofficial, off-the-record personal opinions.

Health care coverage initiatives to benefit children and unemployed persons are likely to be proposed, but have little chance of enactment; children are seen as well provided for under current Medicaid law, the strong economy and high employment levels lower concern for unemployed issues, and the effort required to pass the Kassebaum-Kennedy legislation needs time to settle. Tax proposals, such as medical savings accounts (MSAs), and ERISA amendments have no constituency; also, the MSA demonstration in Kassebaum-Kennedy will forestall further action. Medicaid is far less an issue than in the previous Congress, because spending has fallen unexpectedly, the bitter fight over block grants makes them unlikely to be revisited, and the administration is likely to enhance state flexibility through waivers. Medicare will be the subject of substantial action to defer impending insolvency temporarily, but there is virtually no chance that definitive long-term solutions will be enacted even though the underlying fiscal problems are thoroughly understood and recognized. Managed care will be the venue for numerous proposals designed to address specific consumer and quality issues.

Four bitter years of fighting over health care issues has raised awareness of the problems, but has produced a political chemistry that is too rancorous to permit passage of significant legislation in the near future.