After Budget Battle: Health Care

AS the White House moves from battle to battle over its budget, it is preparing to launch a whole new war.

Sometime within the next month, according to White House aides, President Clinton will send a health-care plan to Congress.

The rough and tumble that follows, says one Senate aide who works on health legislation, "will make [budget] reconciliation look like child's play."

The White House is battening down for "a real roller coaster in coming months," Ira Magaziner, senior adviser at the White House and director of its health-care task force, said last week in a speech.

The health-care war is the big one for the Clinton administration.

Not that the health-care system is more important to voters than the economy. Voters are ranking jobs as their first concern. But the health-care overhaul is a more clear-cut opportunity for Mr. Clinton to attach an achievement of historic proportions to his presidency.

The difficulty level is towering. Many Democrats are gritting their teeth, awaiting the fury aroused by throwing new health-care taxes on top of the tax increases Clinton has already proposed in his fiscal plan.

The White House has apparently decided not to be stingy. Under the Clinton plan, in a few years, perhaps even by 1996, every American will carry a "health security card" good for a generous package of comprehensive medical services.

This is the single most visible and potentially popular aspect of the plan. "Security is what this health-care debate is all about," Hillary Rodham Clinton told a service workers' union last week. "Can your family have piece of mind? Can you or your child get the quality of care when you need it most?"

But the pivotal question for voters, says Robert Blendon, a Harvard University expert on the politics of health policy, is: "What's the price for me to feel secure? What's it worth to the average taxpayer per month?"

The health-care debate that the White House plans to launch next month will be as complex and arcane as public policy gets. But shortly after Clinton takes it public, middle-class Americans will begin hearing in plain language how much more secure their health insurance will become and how much it is likely to cost them.

The White House must stretch its public support between the attractiveness of the secure new health benefits for all and the added cost.

Although most Americans are satisfied with their health-care plans, many are insecure about them. A job change or health problem in the family can mean loss of insurance coverage. Mr. Magaziner estimates that 50,000 Americans a month lose their insurance.

The Clinton plan is designed to eliminate that insecurity and bring the 37 million uninsured into the health-care system. Universal coverage will not be instant, but spread over a number of years. The faster it phases in the more it will cost. But the administration appears to have opted for a very fast-track option, perhaps as short as three or four years.

Giving Americans secure insurance is politically potent. "The only thing that's visible nationwide is universal access," says Sen. David Durenberger (R) of Minnesota, a moderate Republican and potential Clinton ally in the Senate. Then Clinton can campaign in 1996 by claiming that everyone in America has health insurance, he says. On the other hand, "cost containment is not politically pizzazzy."

The insurance package that the Clinton plan will guarantee will be generous. Administration officials have suggested they will establish a comprehensive core benefits package at a level as high or higher than the benefits 80 percent of Americans now receive.

The more generous the benefits, the more they will cost. The White House, says Dr. Blendon, "is more afraid of individuals not liking the benefits of the plan." He adds: "I'm more afraid of taxpayer revolts."

In 1988, Congress passed the Medicare Catastrophic Coverage Act to help cover the expenses of the less affluent elderly, paid for by the more affluent. It was repealed 18 months later in the face of outraged elderly voters who felt they were paying too much for what they got.

How the benefits are to be paid for will be critical to how the Clinton plan is received in Congress. The White House is leaning toward mandating that employers offer insurance. This sets up a health benefits versus jobs debate, since most job creation occurs in small businesses with the littlest profit margins and least ability to afford health insurance.

These mandates are especially troubling to the conservative Democrats and moderate Republicans that Clinton will need to loop into a winning alliance behind his health plan. Most prefer subsidies to help small businesses pay for these mandates.

The debate will be complicated by the abortion factor. The White House has indicated that abortion services will be included in the basic benefits package. Abortion is likely to mobilize opposition whether it is included or excluded from the package. Most Americans support the legality of abortion - but there is no majority behind federal funding of abortion.

If the administration can thread the needle on its health-care plan, says Republican pollster Fred Steeper, "they could get a big win out of it."