Bitter pill has to come on health reform cost



WASHINGTON -- President Clinton is spending most of the week traveling around the country making the case for health care reform. He is armed with a new and distilled version of his priorities intended to reassure Americans that all he is seeking is guaranteed health insurance coverage for everyone without interference in anyone's freedom in choosing a physician.

But the president is conducting this campaign with one hand clearly tied behind his back. He is practically unable and politically unwilling to deal candidly with the costs of the program.

The answer is that much of the expense would be met either by the so-called employer mandate -- a phrase Clinton and his advisers wish they had never heard -- or by the even more politically unthinkable alternative of a tax increase. Even with the medical coverage scaled back from Clinton's original grand design, no one imagines the plan can be financed solely from "savings" in the Medicaid program and controls on medical costs. Some bitter pill will have to be swallowed.

The problem for the president in preparing voters for that reality is made more acute by doubts about his own credibility nourished by the continuing controversy over Whitewater. At his town meeting in Charlotte, N.C., a questioner told Clinton, "Many of us Americans are having a hard time with your credibility" -- an assessment supported by the data from several public opinion polls.

Clinton's task has been complicated, as well, simply by the intrusion of so many other issues. The new survey made by the Times-Mirror Co., for example, showed more Americans concerned about crime and the condition of the economy than about health care.

The ability of any president to bring his constituents along with him always depends to a large degree on how much general support he engenders. The question then becomes whether he is willing to spend "political capital" to achieve an objective that may involve some pain for those constituents.

But Clinton's store of political capital has been depleted by several factors essentially unrelated. One obviously has been the continued focus on Whitewater, and another has been the success of the health insurance industry and Republican critics in raising questions about his proposals for reform.

But the fundamental problem with health care is not simply one of how much leverage Clinton is in a position to use. Instead, it is the imposing dimensions of the situation he is trying to remedy.

By most estimates there are about 37 million Americans not covered by health insurance at any one time. By administration reckoning, about 80 percent of those people hold full-time jobs and presumably could be reached by inducing or forcing their employers to provide insurance.

Some experts insist those estimates are too optimistic. But even ... TC if they are accurate, there is still the problem of millions of Americans who are going to be difficult to reach because they are unemployed and unconnected to the system in any other way. To achieve Clinton's bottom-line demand for universal coverage is going to cost some serious money, one way or another.

The president and his advisers are correct when they argue that those in the underclass already are forcing others to pay their medical costs through, for instance, the expense of maintaining emergency room services at a level required by the number of people who regard emergency rooms as clinics for routine treatment. And they can make a valid case for savings that would benefit everyone in the long run by cutting overall medical costs and, as a result, insurance premiums.

But there inevitably will be significant transitional costs to carry out any program approved by Congress. The White House notes that Americans say in polls that they are willing to pay something to achieve universal health coverage, but anyone who has been in politics knows that a willingness in the abstract often dissolves when specific tax figures are put before the same voters.

Clinton cannot afford to do that now while he is trying to rebuild demand for his reform plan. Eventually, however, the costs will have to be faced.

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