How Health-Care Plan Affects You

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.

``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.

Part-time workers would pay more than 20 percent of their premium cost, prorated according to hours worked. Someone who worked 7.5 hours per week, for example, would pay 80 percent of the premium while the employer paid 20 percent. Thirty hours per week counts as full time.

With a part-time worker and full-time spouse, however, the employers would divide up their 80 percent share of the family-premium by prorating. PREMIUM COSTS

Many details of what individuals would pay for health care are not clear because no one can be sure how the entirely new, highly controlled, health-care marketplace envisioned by the White House would work.

The cost of health insurance premiums should be held down as companies offering health plans compete for customers. Premium increases will also be closely controlled by a National Health Board. But some health-care providers warn that the caps on premiums could draw premium prices upward as companies stay as close to the cap as they can, fearing the next year's increase will be limited.

Premiums may also have to bear more costs. If the administration underestimated the added cost of its universal coverage, then some of that cost will be carried by tax dollars and some by higher premiums.

In two instances, individuals are very likely to pay more than currently. People who contribute less than 20 percent of the cost of their health plan now will probably have to up their ante to that level, although some employers could still opt to pay more than 80 percent. People whose benefits are more generous than the Clinton standard package will lose the right to deduct the extra cost from their taxes, but only after 10 years into the plan.

Most of the relatively few people who still have such generous benefits either work for the federal government or in the health-care industry. Within a plan, premium prices would vary only by family size. Insurers would be barred from charging more to high-risk consumers. CHOICES

For many people, the Clinton plan will expand choices greatly, since most employers offer a very narrow menu of health plans. Alliances must offer any plan that meets all the qualifications, including a requirement that no plan prices its premiums more than 20 percent above the regional average.

Most of the plans will use managed-care networks, such as HMOs. But each alliance is required to offer one traditional fee-for-service plan, where the consumer uses the health-care provider of choice and receives a bill. These plans would have deductibles set at $200 for individuals and $400 for families and would probably be the most expensive plans available.

Eventually, most experts foresee the market narrowing to about a half dozen large insurance companies and a similar number of HMOs.

``I would be surprised [to see] more than 10 to 15 plans in a region,'' says Mr. O'Donnell of Buck Consultants. JOB CHANGES

Changing jobs does not affect coverage, only which employer pays the 80 percent of the premium. Same with losing a job. After six months, the former employer no longer contributes, and the federal government picks up the employer's share. The consumers with unearned income may still pay their share.

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