Outline of new national health plan emerges gantlet of issues remain Questions abound on implementation

May 18, 1993|By John Fairhall | John Fairhall,Washington Bureau

WASHINGTON -- Anyone trying to follow the twists and turns of President Clinton's health reform plan is bound to be confused -- the story keeps changing.

One day last week, officials said the plan might phase out Medicare; the next day they said it wouldn't. Last month they talked about imposing a national sales tax to pay for coverage for the uninsured; a week later they ruled it out.

"I think the bulk of the people, if we gave them an exam, wouldn't know what we're doing" on health reform, says Robert J. Blendon of Harvard University, an informal adviser to the president's task force on health care reform.

But an outline of the plan is becoming clear as a June deadline approaches: To control the soaring costs of medical care and guarantee every American decent insurance, the president will recommend a radical shake-up in the way health care is financed and delivered. He intends to:

* Require all employers to pay for health insurance, with employees chipping in.

* Offer a standard package of insurance benefits to all Americans.

* Bar insurers from dropping people because of past or current illness, guarantee people coverage no matter where they work and protect small businesses and individuals from exorbitant rates.

* Assure Americans some choice in selecting their doctors.

But Mr. Clinton has yet to make a range of major decisions that may make or break his plan: Whom would he tax and how much? How long would it be before all Americans have insurance? If states are given flexibility to adapt health reform to their needs, as Mr. Clinton has vowed, will there be 50 health reform plans?

How would costs be controlled? Would Americans who want absolute freedom to choose doctors and hospitals have to pay a prohibitively higher price?

There's been lots of speculation about how he'll answer these questions -- and plenty of confusion.

Nothing is final until Mr. Clinton announces his plan -- and even that date is uncertain. Originally scheduled to be released May 3, the plan now won't come out until next month, and the president is under congressional pressure to delay it even longer.

Insurance benefits

More than 80 percent of Americans already have some form of insurance and basically want better health care at the same cost or less.

Recognizing this, the administration is leaning toward recommending a comprehensive set of benefits for all Americans, including mental health and substance abuse services, dental care, prescription drugs and preventive services, say Hillary Rodham Clinton, head of the health task force, and Ira Magaziner, who coordinates it. Abortion also would be covered, though under the guise of general reproductive services.

Some of the benefits, such as drug coverage and mental health care, are expensive additions to what most people have today and may have to be phased in over several years.

The administration also hasn't spelled out what kinds of health practitioners would have their services paid for under this benefit package. Would your insurance plan pay for a visit to an acupuncturist? Chiropractor? Nurse midwife? The states may decide.

Long-term care is another unresolved issue. Administration officials are committed to establishing a program initially emphasizing home and community-based services for disabled and chronically ill people. But they haven't said how it should be paid for.

Last week, Mr. Magaziner said people in need of costly nursing home services wouldn't have to impoverish themselves to qualify for government aid through the Medicaid program, which serves the poor. Marylanders can't qualify now if their assets exceed $2,500. The administration is considering raising the threshold nationwide to $12,000.


Most Americans think they already pay enough for health care. But the administration wants everyone to help pay for coverage of the 35 million Americans who lack insurance. That could cost from $30 billion to $90 billion.

The White House has endorsed higher tobacco taxes and is considering increased taxes on guns, ammunition and alcohol, although beer might be excluded to avoid angering beer drinkers.

Looking for a bigger pool of money, officials are focusing on a payroll tax of 7 percent to 11 percent on employers and 2 percent to 3 percent on workers. The administration also is likely to propose a tax on supplemental insurance benefits -- insurance that people buy above and beyond the standard package of benefits defined by the government.

The biggest potential money-raiser, a national sales levy known as a value-added tax, was jettisoned last month after key members of Congress objected.

Choosing doctors

Polls show that most Americans believe that choosing a doctor is an inalienable right. But to control costs and stimulate competition, the administration wants to create huge health insurance purchasing cooperatives in each state.

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