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No Exegesis

Guess who just won the National Magazine Award for "Excellence in Public Interest"? We did! We won it for Elizabeth ("Betsy") McCaughey's articles on the Clinton health plan. McCaughey "waded through all 1,364 pages of the health care reform package," the judges said, then she "tore it apart." Her " carefully researched" pieces "transcended the coverage in most of the press. More than any other single event in the debate, what she wrote stopped the bill in its intellectual tracks."

So why don't I feel more like celebrating? Is it because, as a New Yorker editor publicly complained, the McCaughey articles seemed to have been " nominated for buzz"? Perhaps. But does The New Yorker not care about buzz? (Tell it to the Easter Bunny.) Is it because my colleague Michael Kinsley, in this space, denounced the initial McCaughey piece as a "screed," and James Fallows, writing in the Atlantic, said its claims were "simply false" and Theodore Marmor, professor of public policy at Yale, told me his fellow health experts of left, right and center consider McCaughey's articles "risible"?

Maybe all these people are just jealous. If they aren't, though, the award to McCaughey has not only validated a misleading view of the Clinton health plan, but also a peculiar idea of how journalists should affect public debate. To help resolve this issue, I have waded through all 9,000 words of Betsy McCaughey's critique and tens of thousands more words of controversy that followed. Here is what I found out:

Did Clinton offer "no exit"?: "If you walk into a doctor's office and ask for treatment for an illness, you must show proof that you are enrolled in one of the health plans offered by the government," McCaughey wrote, describing Clinton's proposal. "The doctor can be paid only by the plan, not by you." In other words, in the Clinton scheme you'd be at the mercy of your insurance plan. Unless it approved, you couldn't pay Doctor Welby to diagnose your stomach pain, even if you were willing to pay him yourself. In her second article, McCaughey specifically reaffirmed that "the bill prohibits doctors from accepting payments directly from you for the basic kinds of medical care" covered by insurance. Hence, "No Exit," the title of her cover story.

It turns out McCaughey misread the bill. It did ban Doctor Welby from accepting both a payment from an insurance plan and extra payment from a patient. (The idea was to control costs by forcing doctors to accept insurance money as payment-in-full.) But if you paid Doctor Welby entirely from your own funds, you could pay him to do anything you wanted. A clause on page 16 of the bill guaranteed this. The White House press office, in its ham-handed response to McCaughey, implied that this escape hatch worked only for medical procedures "outside" the basic services covered by insurance. But the press office misread the bill, too.

The obvious analogy, notes Clinton adviser Paul Starr, was to education. Everybody pays taxes to support public schools. Likewise, everyone in Clinton's scheme would have to pay for mandatory insurance. But if you don't like the public schools, you can use your own money to send your kid to private school. And if you didn't like the doctors your insurance company paid for, in Clinton's plan you could go out and hire your own doctors.

You can argue that Clinton should have offered more choice, enabling the affluent to pay physicians with a mix of insurance and their own money (though we don't let a rich man pay a public school teacher extra to give his kids special attention). But McCaughey's argument wasn't that Clinton didn't offer sufficient choice. The force of her articles derived from her claim that there was "no exit" from his mandatory insurance plans. She was wrong. Clinton's plan also opened a brand new "exit" for patients trapped in health maintenance organizations, giving them the right to see doctors outside their HMO. McCaughey simply ignored this feature.

Would the plan doom fee-for-service medicine? In "No Exit," McCaughey said " fee-for-service (choose-your-own-doctor) insurance" would be doomed because the Clinton bill "outlaws" plans costing more than 20 percent above average. But the bill didn't outlaw such plans. It said the government didn't have to offer them. In practice, Starr points out, fee-for-service plans aren't that much more expensive, and government officials would have a hard time dropping even an expensive plan that nevertheless attracted a big clientele willing to pay for it. (The government could cancel Social Security benefits, too, but it won't.)

Did the plan ominously threaten privacy? McCaughey made a big to-do over the bill's requirement that doctors report "clinical encounters" to a "national data bank containing the medical histories of all Americans." The White House answered: "Not true." An honest--and better--response would have been: "So what?" Virtually all Republican and Democratic reform plans provide for reporting such information, which is sloshing around the current private insurance system already. Clinton's bill actually had stronger privacy protections than its competitors. But individual records of treatment are necessary to help patients, who may have multiple insurers, get their benefits. Besides, wouldn't it be nice to have the national data that would enable doctors and consumers to determine, say, whether pallidotomy, the controversial new Parkinson's disease treatment, actually works? McCaughey's "data bank" hysteria illustrates the pitfalls of the I-know-nothing-about-this- subject-but-I've-read-the-whole-bill methodology. A more comical example was her horror at discovering that the Clinton plan would pay only for "medically necessary or appropriate" treatment--as if all insurance policies don't contain a similar restriction now. A more damaging example was her attribution to the Clinton plan of all the horrors of HMO life--as if Americans weren't already being forced into HMOs and other managed care plans by the millions because that is all their employers offer. Clinton, by providing a menu of plans, would at least have opened up some choice.

McCaughey herself doesn't need journalism awards. The "buzz" from these two articles was enough to propel her into a successful Republican candidacy for the lieutenant governorship of New York. There she has been busy helping to herd Medicaid recipients into the heartless HMOs she denounced in her TNR pieces.

I don't mean to leave the impression that McCaughey's efforts were worthless. She did unearth some juicy provisions, like one steering medical training slots to "racial or ethnic minority groups" (though, like a good GOP apparatchik, she called this inchoate preference a "quota"). She got some things right. But she got a lot wrong. In the process, she completely distorted the debate on the biggest public policy issue of 1994. Give her a medal.

By Mickey Kaus