WASHINGTON -- The fight over the president's economic plan was light sparring compared with the punches that will be thrown over the next big issue on the president's agenda -- his long-awaited health care plan.
Originally due in May, the unfinished plan was put on ice while Congress dealt with the budget and deficit reduction. While that may have been necessary, the delay has cost the president momentum on health care reform and given critics an opportunity to organize opposition.
By the time he outlines the plan in a speech to Congress late next month, health industry groups will have laid a multimillion-dollar foundation for challenging key parts they don't like. Big budgets are being raised for advertising, lobbying and campaign contributions, the tools interest groups have used in the past to block reforms.
But industry groups won't be the only problem. Even though polls show the public wants some reforms, Americans have become more pessimistic about how the president's plan will affect their health care.
Nor is there consensus in Congress about how to proceed on health reform. Though regularly briefed on the plan's progress, lawmakers seem to have grown more cautious about what they'll support, especially if it is expensive. The budget battle has left Congress in an anti-tax mood.
It's no wonder that White House officials have set up what some call a "war room" to map a public relations campaign. The administration knows it faces a ferocious, protracted fight.
Mr. Clinton's plan would drastically alter the way medical care is delivered and financed, affecting all Americans and every aspect of the $930 billion health care business -- roughly 14 percent of the economy.
He will ask all employers to pay for insurance and will propose as much as $40 billion in new taxes so that government can pay for insurance for the unemployed. All Americans, regardless of their health or employment, would be guaranteed a package of benefits that includes preventive services, hospitalization, prescription drugs, some dental coverage and limited mental health treatment and long-term care.
While everyone is in favor of universal access to good health care, the president's plan faces opposition on many fronts -- foremost, the mandate on employers and new taxes. But there also will be fights over abortion coverage, which the president plans to include, a proposed national health budget intended to restrain spending, and creation of giant purchasing cooperatives that would buy insurance for consumers and regulate the health care marketplace in each state.
Opponents charge that the White House plan will undermine quality, limit patients' choices of doctors and bring about a system of governmentally rationed care. They and their congressional allies are ready to challenge any attempt to impose price controls on insurers, doctors, hospitals and prescription drugs.
Critics to spend millions
In fact, one organization calling itself Citizens Against Rationing Health has sprung up, boasting that it will spend $10 million on a "grass-roots media campaign" against the White House plan. The group is headed by Donald Devine, director of the Office of Personnel Management in the Reagan Administration and now a director of the American Conservative Union, and former Rep. Beau Boulter, a Texas Republican.
Asked why he believes the plan will result in rationing, Mr. Boulter says imposition of a national budget -- which would cap all health care spending at a certain level -- would lead to limits on care.
Among groups likely to support the administration, the AFL-CIO is expected to provide most of the financial muscle -- more than $3 million, but a fraction of what opponents can raise.
Consumer groups say they'll depend more on low-budget activities to rally support, like the 1,000 house parties that Families USA is planning soon after the president announces a plan in late September. The American Association of Retired Persons will spread the word to its 33 million members through its magazine and numerous community meetings.
But big, wealthy industry and professional groups also will engage in trench warfare, with the American Medical Association encouraging its 290,000 physicians to distribute literature to patients.
"The AMA plans to use extraordinary means to communicate with patients, physicians, the Congress and other decision-makers," says an internal AMA document. "Plans include patient materials, advertising, press conferences and releases, appearances on TV and radio, 'town hall' forums and a live teleconference."
AMA officials refuse to say how much they'll spend on campaign contributions. But from all indications, spending by the health industry will reach record levels in advance of the 1994 elections. For the 1992 elections, when health reform became an issue, the industry -- including doctors, drug firms, hospitals and nursing homes -- gave nearly $15 million to congressional candidates, a 36 percent increase from 1990, according to the nonprofit Center for Responsive Politics.
In Congress, even administration supporters such as Rep. Benjamin L. Cardin, a Maryland Democrat who sits on a key health subcommittee, are urging the president to delay big, new taxes that would pay for coverage for many of the uninsured.
While he is "very pleased about the philosophical direction" of the White House on reform, Mr. Cardin says he wants cost controls put in place before new taxes are committed -- even if that means delaying the goal of universal coverage.
"I am concerned they may try to bite off too much at one time," Mr. Cardin says.
Mr. Clinton is receiving a similar message from moderates. A new paper prepared by Robert J. Shapiro of the Progressive Policy Institute, the think tank of the Democratic Leadership Council that Mr. Clinton once headed, urges the administration to proceed slowly for fear of damaging the economy.
Rank-and-file Democrats in both chambers are split among competing health care reform camps or are simply undecided. Republicans are increasingly united around opposition to an employer mandate, but divided about a reform plan of their own.
The best thing going for reform is that many lawmakers in both parties want something to pass in advance of next year's congressional elections. Optimists also note that among Republicans, who stood as a bloc against Mr. Clinton's deficit reduction legislation, there are many who are serious students of health care and advocates of reform, albeit not quite the type the president favors.
"I think you are going to have three groups in Congress," says Dr. James S. Todd, executive vice president of the AMA and its top lobbyist. "You're going to have the far left that says the plan doesn't go far enough, you're going to have the far right that says the plan goes too far, and then you're going to have a whole bunch in the middle who don't know which way to go."
On what might be termed the left is Rep. Jim McDermott, a Washington state Democrat and physician at odds with the AMA over reform. He is leading the charge for a Canadian-style plan in which the government would pay all health care bills. This approach would eliminate insurance companies and premiums but require people to pay taxes to pay for health care, which would continue to be provided by private doctors.
Although 86 members have endorsed this legislation, the largest group of lawmakers in favor of any health reform plan, the Clinton administration won't even consider it. White House officials believe it's too controversial because it would substitute taxes for premiums paid by employers and employees.
A plan to control costs
Conservative Democrats, among them Rep. Jim Cooper of Tennessee, are promoting a plan that, like Mr. Clinton's, would encourage cost control by creating consumer cooperatives for the purchase of insurance. But these Democrats oppose new taxes, national budgets and employer mandates.
Many Republicans in both chambers are ideologically allied with Democratic conservatives on health care reform.
Perhaps the biggest philosophical difference these Republicans have with the administration is over the question of how much fixing the health care system needs. While the White House argues that the system is broken, opponents point to the high quality of care most Americans receive and the fact that roughly four of every five are insured.
Reform advocates point out how precarious that insurance coverage is. Because most workers receive insurance from their employers, losing a job means losing coverage at a time when health care costs are rising rapidly. Some 35 million Americans above the poverty line are uninsured, government data show. Moreover, insurance companies often deny coverage to people with health problems or who are at risk of developing them.
Americans, says Representative McDermott, "know they're one paycheck from nothing."
Public enthusiasm low
Against this backdrop, the administration is selling health reform as "security" and "peace of mind," asserting that even the best-insured Americans can't count on coverage without reforms that make access to care universal and also control costs.
It's a point the president may make in mid-August, at the National Governors Association meeting in Tulsa, Okla., where his aides say he'll probably make the "pivot" from the budget and deficit reduction to health care.
Polls show he'll have his work cut out for him. While most Americans say they want reforms, when pinned down they complain mainly about prices charged by doctors, drug companies and hospitals.
A recent poll by ABC News and the Washington Post found that a majority of Americans believe that under Mr. Clinton's plan they will end up paying more for lower quality care.