WASHINGTON -- Just one month before President Clinton is scheduled to send Congress an ambitious proposal to guarantee comprehensive health care for all Americans, administration officials are beginning to realize that it may involve huge costs and tax increases bigger than any previously proposed.
The White House has spent 12 weeks developing ideas for guaranteeing all Americans a rich package of health benefits. But only recently has the task force begun to focus on the costs.
Mr. Clinton would probably finance his health plan by asking Congress to impose new taxes, amounting to hundreds of dollars a year even for middle-income families, including millions who already get health insurance coverage through their employers.
In return, the administration says, the health plan would provide peace of mind for all Americans because people would be assured of coverage if they moved, changed jobs or became sick.
Officials say they cannot yet estimate totals because Mr. Clinton has not decided what the precise ingredients of his package will be and because even the members of the health-policy team cannot agree on reliable figures for individual elements of the plan.
But in February, Ira C. Magaziner, manager of the President's Task Force on National Health Care Reform, said in a memorandum that "universal access could mean $30 billion, or $90 billion of additional annual expenditure by the government by 1997."
The ultimate cost may be toward the upper end of that range if Mr. Clinton's proposal includes many of the items now under discussion.
Robert D. Reischauer, the director of the Congressional Budget Office and Congress' chief economist, said these matters were "so complex and the data so limited" that reliable estimates were probably impossible.
"We're going to have to get up to the edge of the cliff, cross our fingers, shut our eyes and jump," Mr. Reischauer said.
What follows is a description of the potential costs of the individual health plan elements being discussed and the possible sources of revenue to finance them:
Huge expenses foreseen
Providing coverage for the uninsured would increase their use of care and improve their health, but would also contribute to an increase in spending.
"If you give people an insurance card, they will go to the doctor more often," said John F. Sheils, a vice president of Lewin-VHI, a consulting concern that specializes in medical economics. "The uninsured use about 60 percent as much care as insured people with similar characteristics."
Mr. Sheils said health care spending for uninsured people would rise sharply, by $30 billion a year, if they all became insured. The uninsured now get $41 billion a year in medical services, including what they pay for themselves as well as what they receive from public hospitals and programs.
To prevent overuse of medical services, administration officials would encourage patients to see general practitioners or family doctors before going to specialists.
One of the major unresolved questions is whether to upgrade Medicare, the federal health insurance program for 35 million elderly and disabled people, to include all the benefits now offered by private health-maintenance organizations (HMOs). Such enhancements could cost $15 billion to $20 billion a year.
These other elements are under consideration:
PRESCRIPTION DRUGS -- It would cost the government perhaps $10 billion a year to provide insurance covering the cost of prescription drugs to people who do not have such coverage.
The Federal Health Care Financing Administration, which runs Medicare and Medicaid, estimates that $44 billion, most of it private money, will be spent on prescription drugs for people outside hospitals this year. If the government required employers to cover prescription drugs as part of the standard package of employee health benefits, it would, for political reasons, almost certainly have to provide drug coverage under Medicare as well.
Elderly people account for 13 percent of the population, but they are responsible for 34 percent of all spending for outpatient prescription drugs. Medicare generally does not cover the cost of such medications outside a hospital.
LONG-TERM CARE -- Standard health insurance policies do not cover the cost of nursing homes or medical and social services provided to people in their own homes over a prolonged time. Medicaid, the federal-state program, finances a substantial amount of such long-term care for low-income people, at a cost to the federal government of $35 billion a year.
But many other people need such care. Donald N. Muse, a statistician who has worked for the Congressional Budget Office and for the Medicare actuary, estimates that "a medium-size package of long-term care would cost the federal government $50 billion a year," beyond what it already spends.