In monarchies, when the king dies, the people say "The king is dead; long live the king" because there is always another monarch in the line of succession ready to accept the crown at the moment of the king's death. So it is with health care reform.

In 1993, the Health Security Act (HSA), that mammoth 4-pound, 1342-page Clinton/Magaziner blueprint for a better health care world, the very one that Harry and Louise debated and decried in every living room in America, sank to the bottom from its own weight. There were some who said that health care reform was dead in our lifetime, and even jokes appeared: Hillary Clinton asks God if we will ever see health care reform. God replies: "Yes. But not in my lifetime."

Four years later, after some modest interim changes in federal health policy such as improved guarantees for insurability (established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)) and some tinkering with mental health parity and hospital maternity length of stay, we are at it again. The Balanced Budget Act "BUBBA," signed into law on August 5, 1997, lays the groundwork for conversion of the Medicare program into a "managed competition" model, not unlike the essential organizing principle of Clinton's HSA. Quickly emerging on the scene is the report from the President's Commission on Consumer Protection and Quality in the Health Care Industry. The Commission will first enunciate a Patient Bill of Rights this fall, followed next spring by a more technical document describing various approaches to quality in health care and allocating responsibility to the various parties: purchasers, providers, consumers, and government. This Commission's report is intended to create a framework for new legislation, the forebears of which are already in the Congressional hopper. Next year, with elections blowing in the El Niño winds, members of Congress and their campaign opponents will want to impress the electorate with their concerns for all the problems caused by managed care. Look forward to a major debate on consumer protection standards in health care and to possible legislation during 1998.

The President's Commission Bill of Rights product, delivered before Thanksgiving 1997, is familiar to many of us in Kaiser Permanente. Access to emergency care and to specialists, choice and continuity of care, information disclosure, and appeals of health plan determinations, participation in treatment decisions, confidentiality of medical information, quality improvement, and nondiscrimination among health plan members are essential elements also of the Kaiser Permanente Principles for Consumer Protection, announced in September with our partners Group Health Cooperative of Puget Sound, HIP Health Insurance Plans, Inc., AARP, and Families USA. It surprises none of us to see these principles defined in the Commission's report. What the Commission has not recommended is how to implement these concepts. Powerful and opposing forces from the business and health plan and insurance communities on the one hand, and from consumer advocates on the other have paralyzed the Commission and torpedoed any hope once entertained that we would know what to do with the principles, once articulated. For that reason, do they deserve the lofty title "Bill of Rights," as guaranteed by the highest of our laws? The principles, unless they become legally enforceable national standards, will have moral standing only. Congress will wrestle with the implementation issue for the next year and will probably fail to resolve the conflicts of federal versus state regulation or of private accreditation versus governmental mandates.

In an election year, don't place your bets too early. Senator Jim Jeffords, Chair of the Senate Labor and Human Resources Committee, has circulated several drafts of a proposal that would establish broad standards by law and would set up a Health Quality Council to fill in the details and to monitor compliance. Warm-up hearings on the House side this fall have considered Rep. Charlie Norwood's bill (HR 1457), which carries some of the same notions forward in a much more punitive and heavy-handed fashion. Several other copycat bills are already crowding into the inside-the-beltway marketplace of ideas. Do not be astonished at the large number of cosponsors claimed by some of the principal sponsors of these proposals. Every House seat and a third of the Senate seats open for the constituents' pleasure just a year from now. What is better grist for the campaign stump speeches than a claim to protect all consumers from the ravages of managed care? Many politicians will want to carry that message home. Rhetoric, however, does not guarantee passage of legislation.

If something does pass next year, will that appease the angry health policy gods once and for all? If pigs could fly ... unfortunately, the process does not end until we regain a steady state in the health care sector. With the burgeoning size of the aging population and the specter of both a crumbling Medicare system and increasing numbers of uninsured persons in the years to come, turbulence will continue, perhaps for the professional lifetimes of all who read this. Many have written off a new "baby boomer" Presidential Commission already organizing to consider long-term solutions to the Medicare problem. The prospect of renewed inflation and steep premium increases in the private medical markets has everyone worried about the implications for our country's miraculous sustained economic growth of the economy during recent years. A steady-state equilibrium seems far away. Look forward to many years of legislative interest in health care reform.

The old saw, "To a hammer, the world looks like a nail" accurately describes the legislative process. Some believe there is no problem so complicated that a simple legislative solution will not fix it. Unfortunately, unintended consequences of the most well-meaning and well-crafted laws are likely, especially in a field as complex as health care. More powerful than the logic of reasoned policy, however, is the political pressure to demonstrate fulfillment of campaign promises. Next year will be hairy for all involved in the health policy arena. Now is the time for all committed health care professionals to learn the issues and to voice their views about the nature of the problems and about the desirable choices for solutions to these enigmas.

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