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How Health-Care Plan Affects You

By Marshall IngwersonStaff writer of The Christian Science Monitor / September 24, 1993



WASHINGTON

THOSE Americans who are happy with the health-care plans they have now, except for some working for very large companies, are unlikely to keep them under the Clinton health reform proposals.

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``Impossible,'' says John O'Donnell, director of health programs for Buck Consultants, which advises on employee benefits. But all Americans, including the poor or unemployed, would have a generous health insurance plan that compares well to the best offered currently by major corporations.

The Clinton plan is ``covering things that no Fortune 500 company covers,'' says Bob Eichman, a principal at Foster Higgins, another benefits consultant.

If the Clinton health plan were to become law as proposed, it would radically alter the consumer's position in the health-care market - and in the space of three years. The most radical shift is that it would end the insecurity of many Americans over health insurance. They would no longer be at risk of losing insurance or paying more when changing or losing jobs.

In the brave new world of health care, at least 70 percent of the public would purchase health-care plans through a menu offered by a regional health alliance - a quasi-governmental agency that would act as broker and regulator between consumers and companies offering plans.

The exceptions would be people who work for corporations with more than 5,000 employees and that opt to create their own alliances; Medicare recipients; jobless Medicaid recipients; and Defense Department employees.

Every plan carried by a health alliance will offer the comprehensive benefit package guaranteed in the Clinton proposal. Employees pay 20 percent of the premium and employers the rest.

Everyone has to play. The federal government will subsidize small, low-wage employers and low-income families, but all employers must contribute to the premium cost of all employees and all employees must enroll in a plan. Those who do not will be enrolled automatically in the cheapest plan available locally. THE BENEFITS

The basic benefit guarantee for all Americans - including legal residents but not illegal aliens - covers the range of doctor, hospital, pharmaceutical, ambulance, and mental-health services. It covers nursing facility stays up to 100 days per calendar year. It covers eyeglasses and dental care only for children under age 18.

It's unclear whether nonstandard treatments such as chiropractic would be included. Most traditional insurance plans cover chiropractic treatment, but only 40 percent of health maintenance organizations (HMOs) do. Medicare would be expanded to pay for prescription drugs. A separate program would cover long-term care. WHO PAYS WHAT

Out-of-pocket expenses for health premiums and deductibles or copayments are capped at $1,500 a year for individuals and $3,000 for families. Most people will not bump into those ceilings. If they do, the government pays the difference.

The self-employed would pay more, since they pay the whole premium cost themselves. But that cost would be fully tax deductible. Now it is only 25 percent deductible. The self-employed would also benefit from limits on health costs to business. The Clinton plan would cap business health insurance costs at 7.9 percent of payroll costs, and as low as 3.5 percent for small, low-wage companies.