Health expenses, person's income may be linked Clinton considers use of sliding scale to control costs

June 02, 1993|By Los Angeles Times

WASHINGTON -- Out-of-pocket expenses that most Americans would pay for medical services under the emerging federal health care plan are likely to be tied to their income levels, with wealthier patients assessed higher annual deductibles and service fees, knowledgeable sources said yesterday.

The rationale is that those of greater financial means can better afford steeper deductibles as well as higher fees each time they visit a doctor or enter a hospital, sources said.

The purpose is not to tap into new sources of revenue, they said. Instead, deductibles are being included under the plan to make consumers more aware of costs and to serve as a deterrent to excessive use of medical services, perhaps especially by the millions of newly insured Americans under the administration's proposed universal coverage plan, the sources said.

The provision -- likely to apply to all but the poorest of Americans -- would also be in accordance with the dual themes of "personal responsibility" and "paying one's fair share" that are the hallmarks of many speeches by President Clinton and first lady Hillary Rodham Clinton, particularly on health care and welfare reform.

No final decisions have been made on the so-called cost-sharing proposal, including the precise formula for calculating annual out-of-pocket payments, sources said.

Sources said current thinking in the administration is that a cost-sharing formula tied to income levels should be required even of those with incomes at or just above the federal poverty level. This could mean, for instance, that people at the poverty level might have to pay $5, or possibly less, in co-payments, sources said. People living below the poverty level would not be charged out-of-pocket fees.

The president is expected to make the final decisions on his health care reform plan in the coming weeks. The plan was to be unveiled later this month, but administration officials said yesterday that that timetable is increasingly unrealistic.

Officials had hoped Mr. Clinton would lay out the plan with a speech to Congress on June 22. But for that to happen, he needs to make a series of decisions soon on its key elements, ranging from the overall size of the benefit package to the tax structure to be used to pay for it.

Aides originally planned to schedule meetings for those decisions last week but had to abandon the idea because Mr. Clinton needed to concentrate on House approval of his budget. Now, with the president preoccupied with internal White House staff changes, picking a Supreme Court nominee and strategy for getting his economic program through the Senate, those meetings seem unlikely this week, either, aides said.

If Mr. Clinton cannot meet the June schedule, the health plan would remain under wraps for at least a month because the president plans to be in Tokyo for the annual economic summit of the major industrial nations during the first week of July and on vacation after that.

Under the co-payment proposal, the one major category of health services for which no payments will be required is prevention services, such as childhood immunizations, sources said.

In most employer-sponsored health plans, annual deductibles average about $200 for individuals and $400 for families, meaning that the insurance coverage does not kick in until those out-of-pocket ceilings are met, regardless of income.

Co-payments are fees that a person is required to pay out-of-pocket for each visit to a health care provider after the deductible ceiling is surpassed. Those payments typically average about 20 percent of the total charge.

The administration's emerging proposal to tie cost-sharing to income levels is also in line with its current intention to seek a payroll levy from both employers and workers as the chief funding mechanism to pay for health care reform.

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