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interests associated with various disease con-

plans would cost between $134 and $160 a

stituencies and health care specialties. Groups

month, after taxes, per person, or between

$350 and $500 for a family plan.39 Some of the

battled each other to make sure that their needs

or services were included in the list of covered

cost would be offset by subsidies, on a sliding

services. The list was repeatedly revised to

scale, so that a single person making $23,925 a

reflect, not the best medical judgment, but out-

year would pay $18.46 per week for health

insurance.40 That would still be nearly $1,000

side pressure. The legislature repeatedly inter-

vened. The U.S. Office of Technology Assess-

per year, a substantial burden for someone in

ment concluded that Oregon's prioritization

that income range.

plan "has not operated as the scientific vessel of

The Heritage Foundation has taken per-

rationing that it was advertised to be. Although

haps the least prescriptive approach, with a

initial rankings were based in large part on

mandate for catastrophic coverage, defined

mathematical values, controversies around the

essentially as a "stop loss" policy protecting a

list forced administrators to make political con-

family against total health care costs above a

certain level.41

cessions and move medical services `by hand' to

satisfy constituency pressures."45

Whatever the initial minimum benefits pack-

age consists of, special interests representing var-

And when the Clinton administration pro-

ious health care providers and disease con-

posed a minimum benefits package as part of its

stituencies can certainly be expected to lobby for

1993 health care reform plan, provider lobbying

inclusion under any mandated benefits package.

groups spent millions of dollars in advertising

To see this in action, one simply has to look to

calling for the inclusion of specific provider

state mandates for health insurance benefits.

groups or coverage of specific conditions.

The number of laws requiring that all insurance

Public choice dynamics is such that

policies sold in a state provide coverage for speci-

providers (who would make money from the

fied diseases, conditions, and providers has been

increased demand for their services) and dis-

skyrocketing. In the 1960s there were only a

ease constituencies (whose members natural-

handful of such mandates, but today there are

ly have an urgent desire for coverage of their

more than 1,800.42 The list includes mandates

illness or condition) will always have a strong

incentive to lobby lawmakers for inclusion in

for coverage of hair transplants (Connecticut,

any minimum benefits package. The public

Massachusetts, Maryland, Minnesota, Missouri,

at large will likely see resisting the small pre-

New Hampshire, and Oklahoma), massage ther-

mium increase caused by any particular addi-

apy (Florida, Maryland, New Hampshire, and

tional benefit as unworthy of a similar effort.

Washington), and pastoral counseling (Maine

Public choice

and North Carolina).43

It is a simple case of concentrated benefits

dynamics is such

and diffuse costs.

Or consider Oregon's attempt to prioritize

Medicaid services. In 1992 Oregon guaranteed

that providers

all state residents under the poverty line a basic

and disease

Spiraling Downward toward

level of health care. At the same time, because

National Health Care

constituencies

funding was limited, the Oregon Health

Services Commission drafted a priority-ranked

will always have

list of medical services available to Oregonians.

Individual mandates cross an important

a strong incentive

The state would fund services deemed priority

practical and philosophical line: once we

on the basis of such factors as cost, duration of

accept the principle that it is the government's

to lobby

a treatment, benefit, improvement in the

responsibility to ensure that every American

lawmakers for

patient's quality of life, and community values.

has health insurance, we guarantee even more

inclusion in any

Services that did not qualify under those crite-

government involvement with and control

ria would not be funded.44 However, political

over large portions of our health care system.

minimum

Compulsory, government-defined insurance

calculations quickly became part of the ranking

benefits package.

opens the door to even more widespread regu-

process, with the program a battleground for

7