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US proposes radical reform of Medicare

In contrast to the long campaign for health reform two years ago by President Bill Clinton, the Republican congressional majority has taken little more than six weeks to run the bill through Congress. Some health policy analysts have complained that experts have barely had time to read the legislation. The House version must be melded with the Senate's bill, which is expected to be voted on later this month. Little has been disclosed about the Senate bill except that it is likely to be less radical than the House version.

The House bill got a huge boost last week when the American Medical Association withdrew its doubts and gave full support to Speaker Newt Gingrich and his fellow Republican leaders. In a flyer sent to its members the association applauded the Republicans' promises that doctors' fees would not be cut severely, that malpractice awards for pain and suffering would be limited to $250000 (pounds sterling158000), and that almost all federal regulations of doctors' laboratories would be repealed. The Democrats said that the association had "sold out." They claimed that patients and hospitals would suffer so that doctors' fees could be maintained.

But policy experts have not yet identified who will be hurt most by the new limits. Most seem to think that hospitals will lose the most, and some hospitals, especially teaching hospitals, expect revenues to fall, forcing many to close.

The fundamental goal of the bill is to move elderly people away from fee for service payments to hospitals and towards prepaid health schemes in which doctors and hospitals are paid agreed capitation fees in advance--more similar to how Britain's general practitioners are paid.

President Clinton has promised to veto such radical reform as passed by the House. The Republicans, however, hope to include their reform of all government sponsored medical insurance (for elderly, disabled, and poor people) in one omnibus budget bill that will be almost impossible for the president to veto without sending financial markets into chaos.--JOHN ROBERTS, North American editor, BMJ

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