THE United States health-care system would likely take a fundamentally different direction under a Clinton administration than in a second Bush term.
Each contender has outlined a very different plan for strengthening the health-care safety net and containing its oppressive costs.
But perhaps the most important difference is that Bill Clinton's plan is far more likely to actually take effect than George Bush's, according to health-policy experts from several viewpoints.
Mr. Bush proposes giving vouchers to the poor of up to $3,750 per family to shop for health insurance. More-prosperous families would get tax credits up to the same amount.
To keep costs down, he would encourage the kind of managed care that health-maintenance organizations provide and rely on competition between such organizations.
Mr. Clinton would require businesses either to supply employees with insurance or to pay into a public plan. The poor would be subsidized in the public program.
To contain costs, he would have a national standards board cap total health-care spending nationally, giving states the option of deciding how to meet their targets.
The plans have "a very important philosophical difference between them," notes Paul Feldstein, a professor of management and health policy expert at the University of California at Irvine. The Bush approach relies on competition to set market rates for health services, with no guarantee that those rates will be low. The Clinton approach sets arbitrary caps, which could lead to other costs, such as longer waits.
But the best-laid plans of the candidates are only part of the picture of what may actually happen in health-care reform.
"If Clinton gets in, we would likely see the kind of plan [Maine Democrat Sen. George] Mitchell has proposed," says Dr. Feldstein. "If Bush gets in, I'm not sure anything would get done."
"It would be hard for me to believe that President Bush would seriously push ahead on health- care reform," says Robert Blendon, a Harvard University political scientist who specializes in health-care policy. "I don't think he cares very deeply about the issue."
Clinton, on the other hand, would "absolutely" have a plan enacted at least by the end of a four-year term, Dr. Blendon says.
"The Bush administration has not made health care reform a priority," says Judith Feder, co-director of the Center for Health Policy Studies at Georgetown University. If Bush is reelected, the country would probably see only some nibbling at the edges of reform of the insurance industry and malpractice law, says Feder, who has advised the Clinton campaign on health policy.
President Bush has not yet drafted and introduced a bill containing the major elements of his health-care reforms. One reason, presumably, is the cost. Another is that Congress is unlikely to enact it.
Neither of those reasons is likely to change with the new Congress. The budget deficit remains vast. And although Congress will have more new faces than in a half century, there is no evidence yet that it will become more conservative or substantially more Republican or otherwise more receptive to Bush initiatives.
The Clinton plan, meanwhile, is broadly similar to the "play or pay" system supported by many key leaders in Congress, from House majority leader Richard Gephardt of Missouri to Senate majority leader George Mitchell of Maine.
Most of these plans require businesses to supply insurance or pay a payroll tax into a public program.
Clinton has not announced yet whether he would levy a payroll tax or have businesses pay in some other way. And his cost-containment plans are more aggressive than most plans on Capitol Hill.
The Clinton plan would not be a shoo-in. It levies a heavy burden on businesses, especially small businesses that can less afford health-insurance costs. It also pinches the hospitals, clinics, and physicians that supply health care with its spending caps - which apply to all health-care spending, public and private. These groups are powerfully represented in Congress.
"There's no single plan that I can think of that doesn't make some group go ballistic," Dr. Blendon says.
"If we're going to save $20 billion or $30 billion a year on health care, somebody's got to give up something," he adds.
If members of the new Congress read an ambivalent health-care mandate into their own elections, Blendon says, then reaching consensus will take a couple of years, he says.
The Clinton campaign stresses that the new expenses in its plan would only be phased in as the cost controls produced savings.
The Bush administration gave out an unexpected signal on its present health-care policy last week when it turned down Oregon's request to ration Medicaid care to only the most necessary medical procedures. The administration decided, with little warning, that the plan discriminated against the disabled.
Until last week, the administration's operating principle seemed to be that states could design any program that didn't cost the federal government more money. Clinton campaign advisers acknowledge that his plan would give less independence to the states.