New world of health reform taking shape slowly

April 05, 1993|By Los Angeles Times

WASHINGTON -- Shortly after President Clinton named her to lead the drive on health care reform, Hillary Rodham Clinton described the Herculean task as a "march toward facing reality."

This month, she and the president hit the painful homestretch.

Working day and night since Jan. 25, more than 500 health analysts have assembled an exhaustive array of options. Now it's time for the president and Mrs. Clinton to begin trimming from that wish list, making the first of perhaps hundreds of decisions that will enable planners to put the finishing touches on a proposal expected to be as far-reaching as the Social Security Act of the Franklin D. Roosevelt era.

"It's time to get serious, get down to brass tacks," says one White House official.

Some fundamental choices still have not been made, and many key details will be left to the administrative rules-making process later, sources say.

"There's still a tremendous amount of uncertainties, many different alternatives, many different points of view," says Princeton sociologist Paul Starr, a senior analyst at the White House Task Force on National Health Care Reform, chaired by the first lady. "Things are far from being settled."

Still, the broad outlines of the reform plan are emerging, making it possible to describe in general terms the kind of health care landscape Americans will encounter in years to come.

For many, the contrast will be startling.

At a fundamental level, the Clinton reform plan will create a new health care system and lay down a set of financial incentives designed to steer people into health maintenance organizations, preferred provider organizations and other forms of provider networks designed to hold down costs.

While many such networks already exist, most Americans are not familiar with how they operate. Under them, consumers, rather than going to doctors on a fee-for-service basis, have a lower-cost alternative of visiting primary care physicians who are members of the network. These general practitioners will also serve as "gatekeepers" whose authorization must be obtained before patients may go to more expensive specialists.

The key to making this concept work nationally is the creation of government-certified regional health insurance purchasing cooperatives.

Most Americans would be grouped into such large cooperatives, with consumers able to choose from a variety of insurance networks -- ranging from health maintenance organizations to traditional fee-for-service plans that allow the patient to choose any physician.

All the networks would have to provide a minimal benefits package now being designed by the White House. Consumers who opt for the more generous plans, such as fee-for-service, are likely to pay significantly more to get it, and employers are unlikely to make up the difference, as many do now.

The idea is to create cooperatives that will represent consumers in bargaining with health networks "to make sure they get the best choices and the best deals," Mr. Starr says.

Further details of how such cooperatives will work -- especially in rural areas -- are still being developed behind closed doors in a "war room" at the Old Executive Office Building adjacent to the White House.

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