THE endgame is approaching for the reform of the health-insurance system - the central effort of the Clinton presidency.
By 6 o'clock the evening of Aug. 3, legislative language is due at the House Rules Committee for all the bills headed for floor votes.
On Aug. 2, Senate majority leader George Mitchell (D) of Maine presented the plan he will offer for Senate debate next week.
Mr. Mitchell's plan would be voluntary until 2002. If coverage is not close to universal by then, employers would be required to pay 50 percent of their employees' health-insurance costs.
House members expect that four versions of health-insurance reform will come to the floor:
* The bill put together by House majority leader Richard Gephardt (D) of Missouri, which has major elements of the original Clinton proposal.
* A far less ambitious bipartisan bill under negotiation between five moderate Democrats and five moderate Republicans.
* A GOP alternative by minority leader Robert Michel (R) of Illinois based on Medical Savings Accounts, similar to Individual Retirement Accounts.
* A single-payer bill favored by many liberal Democrats, where the government pays all basic health-care bills, similar to the current Medicare system.
The House is probably going to use a king-of-the-hill vote on health care. This would mean that all four bills are voted on in sequence. Regardless of which bill wins the most votes, the last one to pass becomes the bill that is sent to House-Senate conference committee.
Aid to members
This form of voting developed in the early 1980s as bills got bigger and more complicated. It offers a way for House members to vote for the bill they would prefer, while still giving a strong advantage to the bill that the leadership puts last in the sequence.
The Senate is much looser in structure. When Mitchell takes his bill to the floor sometime next week, other senators will almost immediately begin offering amendments. Republicans will propose their consensus plan put together by minority leader Robert Dole (R) of Kansas as a substitute for Mitchell's plan.
The leadership cannot control debate in the Senate, and as long as Republicans can hold 41 senators in opposition to the bill, they can sustain a filibuster and prevent action. With 43 Senate seats, Republicans expect to use all their leverage.
The Senate is a tougher hurdle to get an ambitious health-care bill over. For this reason, House members would prefer to see a Senate vote first, so they do not have to extend themselves on a controversial vote only to see it rolled back in the Senate. Mitchell may be willing to oblige, but he can do little to control the timing of a vote. He has vowed, however, to hold the chamber in session until the Senate acts on a health-care reform bill.
Tax on tobacco
Mitchell's bill would raise taxes on tobacco almost immediately to extend health insurance to currently uncovered children and pregnant women. It would use subsidies and insurance-law changes to expand coverage of the 17 percent of the population now uninsured at any given time. If 95 percent were not covered by 2002, then employer mandates would kick in.
Even his downscaled version of employer mandates, he said on Aug. 1, will be difficult to push through the Senate.
The Senate GOP plan consists of insurance-law changes common to nearly all reform proposals and some subsidies for families up to twice the federal poverty level. The insurance-law changes would bar insurers from refusing policies to people who change jobs or have health problems.
The House leadership bill, compiled by Congressman Gephardt, aims for universal coverage by 1999 and achieves it through a mandate on employers to pay 80 percent of their workers' insurance premiums. The plan would expand Medicare, which now covers people over 65, to cover the uninsured and employees of small businesses. If costs are not under control in five years, then government fee schedules would be imposed in high-cost states.
The House Republican alternative would require employers to offer, but not necessarily pay for, at least catastrophic health insurance. That means insurance with a deductible that would cover big expenses, should they arise.