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Health Care Loses Its Way in Bureaucracy

By Everett Carll Ladd. Everett Carll Ladd is professor of political science at the University of Connecticut and president of the Roper Center for Public Opinion Research. / June 3, 1994



THE recent flap over the Clinton administration's decision to have the Department of Health and Human Services (HHS) take over the distribution of most childhood vaccines used in the United States testifies to a strange transformation that has occurred in one wing of the Democratic party. The Democrats' distinguishing commitment to liberalism goes back to the presidency of Franklin D. Roosevelt. But only in recent years has a party faction construed liberalism to mean a generalized preference for governmental over private-sector action.

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Last year Congress enacted legislation whose stated purpose was making sure children were not denied the standard vaccinations for reasons of economics. Now legislators of both parties, including such strong advocates of wider immunization as Sen. Dale Bumpers (D) of Arkansas, have criticized the administration for going well beyond the law's basic intent.

HHS has been proceeding with a plan to set up a huge warehouse in Burlington, N.J., for storing and distributing as much as 80 percent of all pediatric vaccines used in the country. The government would buy the vaccines at regulated prices and supply them free to physicians and others who would administer them. The General Services Administration, the federal purchasing agency, would run the warehouse.

Under the plan, even children from high-income families would be entitled to free vaccines as long as this specific benefit was not included in their insurance. Coverage of all children regardless of income was part of the president's original proposal, but Congress had said no to the idea.

On its face, the Clinton administration's decision to establish a highly centralized government system for purchasing and distributing pediatric vaccines is mystifying. For one thing, HHS statistics for 1993 show that between 85 and 90 percent of all 2-year-old children already get the necessary vaccinations through regular private means and established state programs.

Not only does the administration's plan for a much bigger federal presence go beyond congressional demands, it is opposed by many state health authorities. In Minnesota the state epidemiologist calls the Clinton approach a bureaucratic nightmare, which would take ``an already complicated system and make it more complicated....'' Mississippi's state health officer criticizes the plan for targeting the wrong problem: ``The problem is not the cost of the vaccine, but getting it from the bottle into the child.''

In an age when the public is plainly concerned with rising government spending and frustrated with bureaucratic intrusiveness, the Clinton administration is moving to implement a centralized, bureaucratically complex approach to childhood vaccinations that would extend to millions of children already adequately covered. It is poorly designed to meet present needs.

The one evident ``virtue'' of the HHS approach is that, more than any other readily conceived, it would enlarge the federal presence. It embodies in one limited area a value judgment that administration officials bring to many issues and that, in particular, underlies the entire Clinton health-care plan.

The administration has shown itself prepared to pay a very heavy price as it attempts to extend the federal reach. The public has applauded President Clinton for seeking to ``do something'' about health care, but it plainly resists the type of action he wants. Americans aren't familiar with the technical details of this and other proposals. But they have clearly signaled their preference for reform that preserves many features of the present system and avoids centralized government control. By pushing the latter in the face of rising opposition, the administration has surrendered the high ground it held when it took office. It has even managed to give its fractured opposition the upper hand on the issue.

Given their unprecedented investment in public opinion research, it's highly unlikely that Mr. Clinton and his advisers have followed their course thinking it the most popular one. They must have chosen a government-centered approach on childhood vaccinations and on health care overall from conviction that an enhanced federal role was desirable, even though much of the public didn't want it. Recognizing that the tide of public sentiment is still running generally against ``more government,'' Clinton and his strategists apparently concluded that the public's considerable worry bred of escalating health-care costs gave the best opening.

The old (New Deal) liberalism was generally popular. It expanded government's role on areas where experience seemed to justify it: Bolstering the position of groups left behind or weak in the surge of industrialization and providing the additional national regulation that so national an economy had come to require.

The new liberalism, in contrast, lacks popular approval. It comes at a time when much of the public sees government's presence as already too large. What's more, the Clinton administration's enthusiasm for a bigger federal presence carries it far beyond actions that are defensible as meeting the needs of deprived groups.