Washington -- NOW BEGINS the endgame. If everything breaks just right, we will get a better health care system. Otherwise, we will miss a window for reform. And we could wind up with a hodgepodge worse than what we have now.
From the outset, health reform had to marry three seemingly contradictory goals: universal coverage, cost containment and free choice of health plans. For the middle class, universal coverage means guaranteeing that insurance is fully portable -- not vulnerable to discrimination because of pre-existing conditions. For the poor, it means requiring either their employers or the government to pay most of the cost.
In theory, universal health care implies higher costs. But President Clinton's original plan grasped a happy paradox. By universalizing coverage, the system could save a lot of money.
No longer would hospitals and insurance plans play the expensive game of shift-the-cost. No longer would there be endless forms to fill out, wasting the time of doctors and nurses. No longer would insurance companies spend billions of dollars evaluating and rejecting subscribers likely to get sick. And despite greater government involvement, Mr. Clinton's plan promised citizens more effective choice of plans and doctors than most people have now.
Now, after inconclusive action by six different congressional committees, the majority leaders of the House and Senate have crafted floor bills. How do these bills stack up against the original goals?
The House bill, by Majority Leader Richard Gephardt, is actually more far-reaching than Mr. Clinton's. It offers a more generous basic package, charges employers more than Mr. Clinton would, and covers the poor, the uninsured, the unemployed and some small businesses by expanding Medicare. Mr. Gephardt would contain costs by having government mandate hospital and doctor fee schedules by the year 2000 in states where costs rose faster than a federal target.
Mr. Gephardt's expansion of Medicare is a gesture to the 100 or so House Democrats who favor a single-payer system. But his surprising hybrid of Medicare and private insurance, blending a government system with a patchwork private one, invites further fragmentations. Still, the bill has the virtue of providing universal coverage.
In the Senate, Majority Leader George Mitchell has taken a markedly different approach, both in politics and substance. Facing a slimmer Democratic majority and a Republican ability to filibuster, Mr. Mitchell has sought to accommodate the concerns of Republicans and conservative Democrats.
His bill would provide neither true universal coverage, nor hard cost containment. Mr. Mitchell borrows from Tennessee Rep. Jim Cooper's bill, by requiring employers to offer -- but not pay for -- insurance plans. He would help the working poor pay for coverage through a complex system of subsidies.
Mr. Mitchell's bill also borrows the Senate Finance Committee's idea of restraining costs by taxing high-cost insurance plans. If that didn't do the job, he would buck the problem of cost containment to a federal commission. And if fewer than 95 percent of Americans are covered by the year 2000, the commission would have to recommend how to cover the uninsured.
Even more than the Gephardt bill, Mr. Mitchell's continues the inefficient patchwork system of multiple health plans, cost-shifting and administrative waste. It also penalizes the working poor by withdrawing their health care subsidy as their incomes rise. It offers free choice only for those who can afford it.
Mr. Mitchell and Mr. Gephardt are among the Congress' most passionate advocates of true universal health coverage. What explains their sponsorship of these imperfect hybrids is, of course, politics.
After months of jockeying, the Republican leadership has made it clear that Republicans will oppose, nearly unanimously, anything close to government-mandated universal coverage. In the House, where Mr. Gephardt has a bare working majority, he responded with a tough, partisan bill. He is gambling that, in the end, even conservative Democrats will resent the Republican obstruction and support his bill for the sake of party unity and to take the trophy of health care reform into the November mid-term elections.
Mr. Mitchell, in contrast, is gambling that his very different approach will attract just enough Republicans -- and conservative Democrats -- to get through the Senate.
It is just barely possible that both bills, despite opposite strategies, will squeak through their respective chambers. It is also possible that these strategies will backfire. Mr. Gephardt's tough partisanship in the House could alienate the Senate Republicans that Mr. Mitchell needs, while Mr. Mitchell's soft bipartisanship could incite conservative House Democrats to oppose Mr. Gephardt with something like the Mitchell bill.
If Mr. Mitchell and Mr. Gephardt do prevail, a House-Senate conference committee could compromise, miraculously, with something close to the original Clinton plan. But if either gamble fails, we could end up with a more costly, more bureaucratic system.
In the end, a tiny handful of moderate Republicans and conservative Democrats in both houses will decide whether the nation gets true health reform.
Robert Kuttner is a syndicated columnist.