The candidates' dilemma is best appreciated with a little perspective, which we now offer in summary.  Section 3 of The Grand Unification Theory covers much of the following in more detail. 

The seeds of our present health care crisis were sown during WWII, when employers began offering health insurance to their workers while wage and price controls were in effect.  The government liked the idea of employer-offered heath insurance, and after the war encouraged the practice by giving employers large tax write-offs for the premiums they paid. Suddenly, most employees in the U.S. had health insurance, insurance that appeared to be "free." Indeed, health care itself looked pretty much free to pretty much everybody during the next several decades.  Consequently there were no incentives for either doctors or patients to limit the health care they used, and the bio-medical-industrial complex flourished over the next decades, to meet the growing demand for ever more exotic, expensive (and, by the way, generally effective) treatments. The spiraling costs of health care were bound to catch up with us sooner or later.

President Nixon actually proposed a national health insurance plan, but it was lost in the Watergate fallout. For the next 20 years, Congress and the executive branch did what they could to institute incremental changes to slow the rising cost of health care.  While many of these changes seemed radical at the time they were instituted, they were actually quite piecemeal and did little to curb rising health care costs. Those costs continued to grow out of all proportion to the rest of the economy. From 1970 until the early 1990s, health care spending increased from 7.3% of the GDP to approximately 13%, from $74.4 billion to nearly $752 billion annually.

Things reached a head during the recession of 1990-91, and when President Clinton was elected he sensed a mandate (probably correctly) to take radical steps to fix the health care system.  Unfortunately, being Clintonians, the plan the Clintons produced was an abomination.  That, and the secretive way in which they produced it, played into the hands of those who claimed that the Clintons' chief aim, rather than fixing health care, was to commandeer 13% of the American economy into governmental control in one fell swoop. The specter of "big government" that the Clintons raised with their health plan put Republicans in control of the House and Senate for the first time in decades, and killed all hope for any kind of Clintonian health care reform in the foreseeable future.

While the collapse of the Clintons’ reform plan in 1994 caused a sudden deflation of expectations, the severe fiscal crisis in health care remained. In fact, awareness of that crisis had been significantly heightened by the Clintons’ campaign to reform health care, and nobody (except, of course, some of the doctors) entertained the delusion that we could simply go back to business as usual.

But as it turned out, a savior awaited.  That savior was, naturally, the same insurance industry that had first supported then scuttled the Clintons' reform plans.  Only now the insurance companies had reformulated themselves into HMOs, had decked themselves out in Gekkonian raiment, and had fully assimilated the language of managed care.

Their proposal was that we turn health care over to the marketplace (i.e., to them,) and let the efficiencies of the marketplace solve our health care crisis.  The resultant enormous savings would be split by shareholders and payers of insurance premiums, thus allowing more people to afford insurance. Because we’re Americans and we know the benefits of capitalism, and because the other choices we faced looked even worse, we all said: go for it.

The result has been, over the past few years, perhaps the most rapid change our health care system has ever seen.  While most of the changes have been real, palpable and material, the biggest transformation of all has been a philosophical one.

For all their faults, the Clintonians have always held to the age-old notion that the basic underlying purpose of health care is to maximize the public good.  Indeed, they believe, this fact is what gives government the ultimate authority to regulate health care in the first place. Only the government can guarantee that the special interests will act in a manner appropriate to public benefit.  (The flaw in this argument, for those of us who are suspicious of Clintonians, is that regulatory bureaucracies often wind up behaving as the biggest, meanest special interest of all.)

What the Gekkonians have given us is a brand new first premise.  The primary purpose of health care, they say, is not to increase public benefit.  How could it be, when health care is merely a business like any other business?  What we should be striving for is to build a well-run business. Since well-run businesses are beneficial to the community, in the end we can expect plenty of benefits to go around. But the fact remains that health care is a business. And the primary purpose of business is to make money.

For years now the Gekkonians have held the field, and they have utterly transformed our health care system. The Clintonians, meanwhile, have taken their vigorous and unabated efforts underground. But despite nearly a decade of "efficiencies" enforced by HMOs on one hand and federal regulators on the other, the cost of health care continues to grow virtually unabated. Today, hospitals are closing; services are being cut; some of our finest institutions are compromising on their missions of training tomorrow's physicians and conducting vital medical research; physicians, having lost all confidence in their ability to make ends meet, are selling their practices - and their autonomy - to the highest bidder; and insurance premiums continue to rise out of sight, driving growing millions of Americans (44 million at last count), mostly tax-payers (whose taxes still subsidize the insurance premiums of the more fortunate), out of the health care system altogether. 

How can all this be happening after years of seemingly Draconian cost-saving measures (and during the most amazing period of prosperity our country has seen in generations)? It is happening because the continued rise in health care costs has relatively little to do with inefficiency or fraud, factors over which we have at least some control. Instead, most of the continued rise in costs is due to two factors over which we have little or no control: 1) the use of increasingly expensive (but increasingly effective) technology; and 2) a rapidly ageing population. In fact, given the demographics (elaborated upon in Section 2 of the Grand Unification Theory), the only way to control costs is to withhold at least some useful medical services from at least some people who need them - in other words, to ration. 

While the presidential candidates cannot admit it, and may well be unaware of it, the need to ration health care is absolute, an economic imperative. The imperative to ration is accepted as an axiom by health care economists.  It is, after all, a simple matter of demographics and mathematics.

So the real problem for both Clintonians and Gekkonians is that their basic premise is wrong. Both subscribe to the American health care myth: that, where health care is concerned, there are no limits. 

Both Clintonians and Gekkonians hold that this myth is essentially correct; that there need be no limitations on our expectations; that all we need to do to get our health care crisis under control is to effect changes in the system - more regulation on one hand, more market efficiencies on the other.

Thus, both Clintonians and Gekkonians are faced by a dilemma. Since they are both wrong in their first premise, neither can offer any truly effective solutions to our health care crisis. (A proposed solution that actually might work is offered in Section 8 of the Grand Unification Theory.)

This will make the health care aspects of Campaign 2000 frustrating to watch. On the other hand, if one can keep a sense of humor about so serious a problem, watching the candidates dance around the issue will offer hours of amusement to the enlightened. 

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