OUT in the stucco stretches of the south Florida suburbs, Teresa Blanco's concern has been escalating. Since her husband changed jobs last fall, she and her two small children have had no health insurance.
The major local public hospital, Hollywood Memorial, has a different problem. It wrote off $28 million of billings last year to bad debt - mostly to working but uninsured people who received treatment they could not pay for.
Now the hospital, working with an insurance company and doctors, has created an innovative program that tries to address both its problem and Mrs. Blanco's. It is one of many innovations around the country testing out ideas that the White House may write into its national health-care plan, scheduled to be unveiled later this month.
Most of the notions fall under the broad concept of "managed competition." Many of these innovations have shown some good results, but few have a long track record or definitive results.
For Teresa Blanco, the choices were few. To add herself and her children onto her husband's employer-supplied policy would cost an extra $396 a month. "We can't afford that," she says. "To begin with, he's not making that much" in his job with an electronics firm.
She was almost resigned to signing up for a managed-care program that cost $209 a month, within the family budget. But they would have to go to the company's own clinics exclusively, and she had heard of problems there, such as the company dropping coverage of people who developed medical problems.
Last week, she was accepted in a plan at Memorial Hospital of Hollywood that will cost only $153 a month. "It's the cheapest I've ever found," she says. "It's wonderful." Cheaper health coverage
The plan is for individuals or small businesses whose employees have have been without insurance for at least six months. Under the plan, a hospital, doctors, and an insurance company have discounted their services for those without insurance.
More than altruism is involved. For both the hospital and doctors, this represents a way to get some payment, even at reduced rates, for services that were going largely unpaid altogether.
"If we were lucky, we got 15 to 20 cents on the dollar" in payment from the uninsured, says Frank Sacco, Memorial's chief executive.
Because the hospital believes its mission is to treat everyone who comes in regardless of ability to pay, the uninsured already had access to health care. In 1992, the hospital performed $36 million worth of what Mr. Sacco calls charity care and another $28 million for working people without insurance. "The vast majority ends up as bad debt," he says. "It's not that they're deadbeats. They just have other priorities."
The hospital will not confirm how deeply it discounted its rates, but it has probably done what the more than 150 doctors who have signed onto the plan have done - accept Medicare-level rates. Nationally, Medicare rates are about 88 percent of the cost of providing services and 30 to 40 percent below retail prices.
The insurance company involved, American Medical Security (AMS) of Green Bay, Wis., agreed to price the policies at cost, without their usual underwriting profit of between 2 and 4 percent. The insurance firm earns goodwill and good press, but also does business that leads to more generous and profitable policies later. "For every policy we write under the access plan, we probably sell two regular policies," says Gail Choate of AMS.
In theory, the plan should save money in two ways. With more people now paying something for their care, those who have been insured all along will have to subsidize less free care. Second, people with insurance are more likely to get checkups and preventive care, which is cheaper than using the emergency room.
The plan has been offered at Hollywood Memorial for only a month. It debuted three months earlier at a hospital across the state in Bradenton. Neither place has had time to see results yet.
The plan could be a preview of what is about to come across the nation, however. The Clinton administration has hinted for months about the possibility of putting cost controls on medical providers. During the campaign, Bill Clinton explicitly proposed global budgets that would cap all medical spending state by state.
On Friday, Hillary Rodham Clinton, who is running the White House task force charged with planning the overhaul of the health-care system, indicated that she may propose voluntary price controls on doctors, hospitals, and pharmaceuticals. Doctors face cutbacks
Many doctors are in the same position as Memorial hospital. They take all patients who come to them, whether they pay or not. Melvin Grossman, a Hollywood neurologist, sets all his rates at the levels established for Medicare and Medicaid patients. "I don't have a money-making practice," he says.
Medical costs are too high, and doctors will have to cut their fees, he acknowledges. "So be it," he says. "But there are physicians who live at or above their means. I know some of them. They're going to have to change their lifestyles."
Efficiencies can save money, too. In central Florida, the Orlando Regional Medical Center has analyzed all its practices by computer for three years and compared their costs to regional and national norms. The tracking helps identify what is necessary and effective. The result is that operating expenses from admissions dropped 2 percent last year after previous increases of between 9 percent and 12 percent annually. The hospital also cut the use of expensive equipment between 4 percent and 40 percent in major areas.
This is the kind of careful management that health-care reformers want to encourage nationally.
Another example of managed competition is the California Public Employees' Retirement System. CALPERS negotiates prices and packages with health-care insurers and offers choices to its 887,000 members. With the leverage of its size, it held down premium increases below the national average for the past two years, although not for the three before that. The Clinton plan probably will put all Americans in such large purchasing groups.