Clinton Signals A Compromise On Health Plan

COMPETING PRESCRIPTIONS. Employer mandates are likely to be softened

IN January, when the lights come back on in the warren of hearing and committee rooms around the Capitol, the great encompassing task for lawmakers will be overhauling the health-care system.

The outcome will be many tedious months down the road, but its contours already can be discerned in the distance.

Most informed observers say that President Clinton will be forced to compromise to his right - adapting key elements of his plan to more conservative views - to win majority support in Congress. The shifts most often mentioned as key to a compromise with conservative Democrats and moderate Republicans:

r Softening the Clinton plan's requirement that all employers supply health insurance to their employees, perhaps by excluding some small businesses or increasing their subsidies.

r Backing away, a bit, from the proposed price controls on insurance premiums, perhaps by granting the president authority to cap premiums in the future if market forces in the plan fail to control costs.

r Stretching out the deadline, now the end of 1997, for setting up the system and achieving universal coverage.

The most critical point of contention is the mandate on employers to provide insurance. One of the most popular bills on Capitol Hill, introduced by Rep. Jim Cooper of Tennessee and Sen. John Breaux of Louisiana, both conservative Democrats, has no such mandate.

Critics of the employer mandate see it as an onerous burden on small, low-wage businesses that will cost jobs. But White House policymakers and others doubt that universal coverage can ever be funded without requiring employers to pay for it.

The Clinton plan was formally submitted to Congress with 100 House cosponsors just last week. In the Senate, two chairmen are struggling for control of the bill: Sen. Edward Kennedy (D) of Massachusetts, leader of a left-leaning Labor and Human Resources Committee, and Sen. Daniel Patrick Moynihan (D) of New York, leader of a more centrist Finance Committee. The assignment could help shape the early direction of the bill.

To the left of the Clinton plan is the Canadian-style single-payer proposal, sponsored by Rep. Jim McDermott (D) of Washington and and Sen. Paul Wellstone (D) of Minnesota. Under this plan, which has 93 House cosponsors, the government pays most medical bills for everybody and sets payment schedules for doctors and hospitals.

To the right of the Clinton plan is the Cooper-Breaux bill, with 57 cosponsors in the House. The Cooper bill uses the same health alliances as in the Clinton plan to enhance the buying power of small businesses and individuals. But it does not require employers to offer insurance, and it does not control premium prices.

A similar plan was introduced in the Senate last week by Sen. John Chafee (R) of Rhode Island. But the Chafee bill has the added requirement that all individuals buy insurance, either through their employer or direct from a purchasing cooperative, with subsidies for low-income people.

The other major plan is further to the right: Sen. Phil Gramm (R) of Texas proposes achieving near-universal coverage through a system of tax credits and subsidies that preserve incentives for individuals to save for health expenses and keep costs down.

Health policy analysts expect Clinton to move toward the Cooper or Chafee proposals, because they occupy the middle ground where the most potential votes are. While the single-payer bill has the most supporters of any single alternative to Clinton, it does not have the votes to pass.

The most delicate balance is between the clear priority the White House is placing on offering universal and secure access to health insurance to all Americans and the powerful public distrust these days of large government enterprises.

``And there's nothing the administration can say that doesn't make this into a large government enterprise,'' says Joshua Wiener, a senior fellow at the Brookings Institution who advised the White House in developing its plan.

Most alterations that cut the role of government in the plan also put universal access in jeopardy. And universal access to a comprehensive package of health care benefits is the president's primary selling point and one irreducible goal.

``That is my bottom line,'' Clinton said in presenting the plan to Congress on Oct. 27. ``I will not support or sign a bill that does not meet that criteria.''

Hillary Rodham Clinton, a few days later, named three bills that met that standard: the Clinton plan, the McDermott-Wellstone plan, and the Chafee plan.

White House pollster Stanley Greenberg said last week that the Cooper-Breaux bill was ``dead on arrival.'' Mr. Breaux responded: ``If Stanley Greenberg feels there is a majority out there who wants a bigger government solution to health care, then he's living in the 1940s.''

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