WASHINGTON -- To understand how difficult it will be to pass a health reform bill, consider the bitter fight that's about to erupt over just one item expected to be in the Clinton administration's plan: universal coverage of abortion.
President Clinton could be putting the entire health reform plan at risk by proposing that the basic benefits package available to all Americans include abortion coverage, as congressional sources expect him to do. The issue is expected to arouse strong opposition within Congress and among the public.
In a New York Times survey last month, seven of 10 Americans said that women should pay directly for abortions and that abortion should not be covered in the basic insurance package.
Abortion opponents are already warning that they will hold health reform hostage over the issue.
Roman Catholic bishops, for example, are eager to support Mr. Clinton on health reform because he seeks to guarantee care for all Americans, but they told the White House in a recent letter that they won't back a plan that includes abortion coverage.
"We believe it would be a moral tragedy, a serious policy misjudgment and a major political mistake to burden health care reform with abortion coverage that most Americans oppose and the federal government has not funded for the last 17 years," said the letter signed by Auxiliary Bishop John H. Ricard of Baltimore, who heads the domestic policy committee of the U.S. Catholic Conference.
Administration supporters are worried about the abortion issue.
"I think it will be a major controversy, in part because there will be such strongly organized opposition," says Democratic pollster Celinda Lake.
But Ms. Lake and others allied with the administration say the president has no choice, given his commitment to abortion rights and the likelihood that proponents would fight if abortions weren't covered.
The debate over whether to cover abortions will focus mainly on the role of the federal government in paying for them. Under the administration's health reform plan, Americans will be guaranteed a package of benefits that will be determined by the government and funded largely by employers, perhaps through a payroll tax that would require a contribution by workers as well.
People who are out of work and workers who can't afford to pay their share of insurance costs would be subsidized by the government -- raising the specter of tax funds being used to pay for abortions, along with other medical services. That would reverse current policy barring federal funding of abortions.
Abortion opponents emphasize this because polls show that while a majority of the public is tolerant of abortion rights, most people don't want the government paying for the procedure. Trying to exploit this, Marion G. "Pat" Robertson's Christian Coalition ran a full-page newspaper advertisement last month quoting from a 1987 letter by then-Sen. Al Gore, in which he said he "consistently opposed federal funding of abortions."
The vice president says that while in the Senate he supported a woman's right to have an abortion even though he opposed government funding through the Medicaid program for the poor. He says he supports Mr. Clinton's position on lifting the federal ban.
On the other side, supporters of abortion rights say the issue isn't federal funding but fairness: Poor women should receive the same benefits as women of means.
Abortion rights advocates, such as Maryland Democratic Sen. Barbara A. Mikulski, also stress that reform legislation contemplated by the president serves to preserve the abortion coverage many women now have in their private insurance plans.
"It is now covered in the preponderance of private sector insurance, and what we should be doing is staying the course," Ms. Mikulski says.
Just how many private plans pay for abortion is not known, according to the Employee Benefit Research Institute, an authority on employer plans. A spokeswoman said private plans might not list abortion as a reimbursable procedure but cover it under the aegis of pregnancy and family services.
Kate Michelman, president of the National Abortion Rights Action League, argues that abortion should be treated as a medical issue. It is one of an array of reproductive services, and if an insurance policy is to cover care for a pregnant woman who intends to have a child, it should cover care for someone who wants to terminate a pregnancy, she says.
"We're all the same woman. You can't divide women into neat little categories and divide one reproductive health service from another, as if they are isolated. They are not," she says. "They are of a piece."
Once Americans understand what Mr. Clinton is proposing, they'll be generally supportive, insist Ms. Michelman, Ms. Lake and Ms. Mikulski. But Republican pollster William D. McInturff says the administration is heading for big trouble in Congress.
"There are Republicans who could be dragged into voting for reasonable health care reform," he says. "But once you start including financing for abortion, if you vote for something like that, you can guarantee in a Republican primary that for the rest of your life there's a chunk of people organizing against you."
And there are anti-abortion Democrats who would probably support health reform but would be "substantially cross-pressured" by anti-abortion constituents, he says.
Robert J. Blendon, a professor at Harvard University's School of Public Health knowledgeable on public attitudes toward health reform, agrees with Mr. McInturff.
"People are mildly 'pro-choice,' " he says. "They're not 'pro' the government paying for it."