Clinton aides divided on health plan scope Cost said to worry some economists


WASHINGTON -- Some of the Clinton administration's top economic officials told President Clinton on Thursday that they had serious questions about the cost and scope of the ambitious plan for health care being developed by Hillary Rodham Clinton, people who attended the meeting said yesterday.

As Mr. Clinton nears crucial decisions on his health plan, his top advisers remain deeply divided on a question at the core of the proposal: how generous to make the standard package of medical benefits that would be guaranteed to all Americans.

These divisions emerged at a spirited, three-hour meeting Thursday night in the Roosevelt Room of the White House, where Mr. Clinton's advisers on health policy and on the economy presented two starkly different alternatives.

The economic advisers generally argued for the more modest package of benefits, which would set higher deductibles and require larger out-of-pocket payments by consumers but less money from the government and businesses, administration officials said.

By contrast, the health policy advisers, with apparent support from Mrs. Clinton, tended to favor the more comprehensive package, which would be less costly to consumers but more expensive for the government and businesses.

The tensions among administration officials presage disagreements likely to erupt on Capitol Hill after Mr. Clinton sends his proposals to Congress. Both alternatives would probably require tax increases, but the size of the increases would vary with the generosity of the package.

The president is buffeted by conflicting pressures to hold down costs and to make the benefits comprehensive.

People who attended the session with the president and Mrs. Clinton on Thursday said no decisions were made then. Mr. Clinton originally intended to send his health care plan to Congress by May 3 but has fallen behind schedule, and the White House now says he will not unveil it before the middle of next month.

Health experts said Laura D'Andrea Tyson, the head of the President's Council of Economic Advisers, and Robert E. Rubin, chairman of the National Economic Council, had espoused the modest plan for people who do not now have insurance.

Several economists in the administration acknowledged that they favored the more modest package of benefits but insisted, as one said, that "the economic team is not a coherent bloc."

The discussion focused on two questions: the generosity of benefits and the timetable for coverage to take effect.

The more modest proposal, described as Plan A, would set a deductible of about $2,000 a year for a family. The alternative, Plan B, would have a deductible of around $400. Patients pay their own health bills up to the deductible, and at that point insurance begins to pay the bills.

Employers and employees would share costs under both plans, but the employees' share would be substantially bigger under Plan A, officials said.

By one estimate, Plan A is more generous than 20 percent of the private health insurance now in effect, while Plan B is more generous than 80 percent of the existing plans.

Benefits would be available under either plan by 1997, but they would be phased in more rapidly under the more generous plan.

The staff of the Task Force on National Health Care Reform, which numbered more than 500, is disbanding. Many people are going back to jobs in government agencies and universities, leaving Mr. Clinton to make tough decisions.

Robert O. Boorstin, a spokesman for the group, said about 30 people attended the meeting on Thursday, which featured a visual presentation of options with an overhead projector. He would not give details of the discussion.

Besides Ms. Tyson and Mr. Rubin, the meeting was attended by Gene Sperling, the deputy assistant to the president for economic policy; Treasury Secretary Lloyd Bentsen; Deputy Treasury Secretary Roger C. Altman; Health and Human Services Secretary Donna E. Shalala; Atul Gawande, a senior health policy adviser to Dr. Shalala; Dr. Philip R. Lee, a nominee for assistant secretary of health and human services; and Stanley B. Greenberg, the president's poll taker.

People who attended the meeting said Mr. Bentsen and Mr. Altman had often sided with Ms. Tyson and the Council of Economic Advisers.

Mr. Greenberg and Mr. Sperling suggested that there were political benefits to be gained from having more generous coverage.

"I've argued all along that it's very important for every American to have a stake in health care reform," Mr. Greenberg said yesterday. "I've encouraged people to think bigger rather than smaller. There is an enormous opportunity here. People want this to happen. It's important that there be genuine benefits and genuine security. A bare-bones program won't excite the imagination of the public."

Mrs. Clinton and Ira C. Magaziner, the manager of her health care group, have supervised development of the president's health plan. In their public remarks, they have held out the prospect of comprehensive insurance coverage providing peace of mind and economic security to all Americans.

But they have offered comparatively few details about how to pay for the new program.

Walter A. Zelman, an architect of the health plan, said at a Thursday conference in Washington that there had been "a fairly significant separation between those of us developing policy and those of us developing the politics of it."

Middle-income families may have to pay higher premiums or taxes under the president's plan, and the administration may risk losing their support unless they get better health benefits than they now have.

A health policy expert who attended the meeting Thursday said the disagreements reflected no personal animosity. "It went very well," the official said.

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