WHEN President Clinton introduced his plan for health-care reform, he stressed ``freedom of choice'' as a key goal. Many Americans took that to mean they would still be able to choose their own doctor or medical treatment.
But the word ``choice'' can have many meanings and apply to many aspects of reform, from the question of abortion coverage to the field of alternative medicine to the area of religious freedom.
As Congress struggles with the many issues of health-care reform and appears headed toward a key vote in August, advocates aiming to preserve freedom of choice are speaking out, hoping to influence the legislation.
Most audible, and most threatening to the entire reform process, are advocates on both sides of the abortion issue.
The legislation being considered includes abortion as a covered benefit. But a strong anti-abortion faction in Congress, backed by the National Conference of Catholic Bishops, threatens to sink reform if abortion is covered.
Equally adamant are some members of Congress who insist on keeping abortion as a basic benefit, but who do support a ``conscience clause'' that allows individual doctors to choose not to perform abortions.
In addition to the abortion debate there is a broader question: How much choice in selecting treatment and providers will Americans have under a federally mandated insurance program?
Already, a large number of Americans use alternative methods in place of or in addition to conventional medicine.
A study published last year in the New England Journal of Medicine found that in 1990, 34 percent of Americans used alternative medical techniques, such as acupuncture, chiropractic, homeopathy, and naturepathy, at a cost of $10.5 billion - a sum equal to the money spent out-of-pocket by Americans for hospitalizations. In most cases, these techniques were used along with mainstream medicine. Increasingly, insurance companies are covering some of the commonly used alternatives.
Who decides benefits?
Health-care reform throws open the question of what should be in a basic benefits package - and focuses attention on the government's role in deciding which methods should be encouraged. Among the groups practicing alternatives, the most active lobbyists are chiropractors.
The American Chiropractors Association (ACA) has a two-part agenda: to ensure that a federal benefits package is defined to cover chiropractors and to advance consumer choice.
``If the benefits package broadly defines `services of health professionals' as those licensed by states, that would be fine with us, provided there is committee report language naming chiropractors by name,'' says Rick Miller, the ACA's chief lobbyist. Every state licenses chiropractors.
To promote consumer choice, the ACA is pushing for a so-called ``any willing provider'' provision. This would mandate that an insurer cover treatment by a provider who fits this criterion. The ACA also wants to prevent any bill from discriminating against types of providers.
At issue is how broadly the government will define ``health-care professional.'' All the health-care bills provide for the creation of a national commission that will set up a system to define ``medical necessity,'' but not to define the appropriate treatment.
Other alternative-medicine groups contacted said they were monitoring the progress of legislation by keeping in touch with members of Congress, such as Sen. Tom Harkin (D) of Iowa and Sen. Barbara Mikulski (D) of Maryland, who are advocates for alternative therapies.
Robert Duggan, director of the Traditional Acupuncture School in Columbia, Md., says his aim is to make sure no procedures are proscribed and that the question of who can provide treatment remains a state issue. About 30 states certify acupuncturists, and some insurance plans cover the practice.
Some advocates of alternative therapies, such as Elliot Greene, president of the American Massage Therapists Association in Silver Spring, Md., argue that the health-care debate is really about financing an ``illness care system,'' and that real reform will happen when people stop looking at just pathologies and consider the ``whole person.''
In the early stages of its study, the White House task force on health-care reform did consider the question of alternative medicine. In March 1993, some 20 representatives of alternative groups met with the heads of the benefits-package team and aired their concerns.
``We were very, very warmly received at the White House,'' says Mr. Duggan, the acupunc-turist, who attended the meeting.
Mr. Greene, another attendee, says he was ``kind of disappointed'' at the lack of follow-up to the meeting. He sees ``big money'' wielding the influence in reform and says society is missing an opportunity for a broader discussion on how health care is addressed.
The question of choice in health care has also come up among some religions. For the Amish and Old Order Mennonites, choice means the ability to opt out of the national health-care system completely. The congressional committees that have called for employer mandates have passed exclusions for those two groups.
Another branch of Mennonites which has its own insurance plan, called Mennonite Mutual Aid, wants to be able to restrict enrollment in the plan to members of the church. Congress is expected to approve that as well.
For the Church of Christ, Scientist, which publishes this newspaper, the situation is equally complex.
The church's position, based on its practice of healing through spiritual means with-out medical care, is that Christian Science care and treatment must be included in any guaranteed national benefits package, either by name or by intent.
So far, none of the legislation covers Christian Science by name. But church officials say they can live with the language in the Senate Finance Committee bill, which does not list specific providers that would be covered, but rather lays out several broad categories that could include Christian Science treatment. The term ``health-care professionals'' could include Christian Science practitioners, church officials say, for the purpose of the legislation.
Currently, more than 30 insurance companies offer coverage for the costs of Christian Science practitioners, in-home nursing care, and care in Christian Science nursing facilities. The church is concerned that health-care reform might jeopardize this private insurance coverage, say church officials.
The church also opposes the present versions of employer mandates, arguing that an employer, such as the Christian Science Church should not be required to buy medical insurance for people who don't want it. The church is seeking to have any employer mandate broadened to allow employers to offer their Christian Science workers an insurance plan that covers Christian Science care and treatment.
One provision before Congress that would use state certification for defining a ``health-care professional'' is unacceptable to the church, because Christian Science practitioners are not certified by states.
``We think we are entitled to coverage, but we have to be treated as a separate system,'' says Virginia Harris, chairman of the Christian Science Board of Directors.
``We say, `if you want universal care, it's only fair that we be included'.''