WASHINGTON -- President Clinton will unveil his ambitious plan to overhaul the nation's health care system tonight before a Congress that seems eager to act on the issue but deeply divided over how far to go.
Rep. Vic Fazio of California, a Democratic leader, echoed the uncertainty of many in both political parties who consider Mr. Clinton's top-to-bottom reform plan an enormous political gamble.
"There is a general assumption that we are going to do something, but a lot of the optimism about the president's program I think is unwarranted," said Mr. Fazio, vice chairman of the House Democratic Caucus.
Amid growing public concern about the cost and quality of health care, members of Congress have been predicting for months that some reform measure would be approved before next year's elections.
Changes thought to have a good chance of becoming law include guaranteeing that people don't lose their medical insurance when they contract serious diseases or move from one job to another.
But no one knows how much further Congress would be prepared to go. In particular, it is uncertain whether Congress is ready to pass a plan that would guarantee health insurance to all Americans, as Mr. Clinton wants.
"The big thing we have to decide soon is how much we are going to try to do right away," said Republican Sen. John H. Chafee, who offered a GOP alternative to Mr. Clinton's plan last week.
"The president's bill is very, very costly," the Rhode Island senator said. "We would like to see the savings in place first before we expand the benefits."
Mr. Clinton begins his effort to reshape one-seventh of the nation's economy with the cooperation of some Republicans, whose continued backing is essential if his plan is to have any chance of success.
"We have Republicans wanting to play a constructive role," said Sen. Edward M. Kennedy, a Massachusetts Democrat who is a longtime champion of national health insurance. "I think the stars are in the right place."
The tentative timetable for consideration of the health care reform proposal calls for public hearings the rest of this year, committee action next spring and final floor votes next summer or fall.
Crafting a 'gumbo'
Although the Clinton administration has signaled its willingness to compromise on many details, aides say the president is
committed to the basic concept of extending health coverage to all Americans, including the more than 30 million who have no health insurance today, and providing the assurance that health benefits won't be threatened by the change or loss of a job.
To achieve those goals, Mr. Clinton has crafted what Sen. John B. Breaux, a Louisiana Democrat, calls a "gumbo": a blend of sweeping new government powers to regulate the delivery of medical services and incentives designed to cut costs by encouraging greater competition.
This compromise approach is already under attack from various quarters, including at least 85 liberal House Democrats who favor a single, national insurance plan run by the government and conservatives of both parties who want far less federal intervention in private business than Mr. Clinton has proposed.
With more than a dozen committees or subcommittees in both houses expected to take up portions of Mr. Clinton's plan, it must clear an unusually large number of hurdles. Major battles are expected over:
* Requiring employers to insure their workers. Mr. Clinton wants to force employers to give their workers health insurance and pay up to 80 percent of the premiums. Critics say that would cause many small businesses to go under and cost the country up to a million jobs.
* Cutting health programs for the poor and elderly. Mr. Clinton would cut the growth of Medicare and Medicaid spending to provide $238 billion in federal money to help pay for the reform plan. Sen. Daniel P. Moynihan, a New York Democrat who is chairman of the powerful Senate Finance Committee, calls these expected savings "fantasy."
* Cost controls. A proposed national "budget" for health spending would be enforced through limits on insurance premium increases. Mr. Clinton says this is critical to slowing down increases in health care spending, but conservatives predict it would lead to rationing care.
* Taxes. The president is expected to ask for $105 billion in new "sin" taxes, most of which apparently would fall on tobacco products. The administration is consulting Congress on whether split such a tax between tobacco products and alcohol, which would force Mr. Clinton to take on two influential industries, rather than one.
* Creating a new federal bureaucracy. A major new federal agency, the National Health Board, would govern the new health system and determine which benefits were included in the national health insurance plan. Conservative critics say that would amount to turning over the best health care system in the world to the federal government. Even some liberal Democrats, including as Rep. Benjamin L. Cardin of Baltimore, say the proposed new regulatory structure would be too cumbersome.
* Abortion. Under the Clinton proposal, abortion services would be offered as part of the basic benefit package. This is a peripheral issue in the broad context of health reform but is politically significant because abortion opponents might try to hold up the plan. Abortion opponents say it would lead to more abortions; abortion rights advocates say any other approach would restrict medical services currently available to those who can get abortion coverage through their insurance companies.
Lawmakers across the political spectrum agree that the public's concerns about health care are so great that at least a minimum package of reforms is almost certain to pass.
These probably would include market reforms to prevent insurance companies from denying coverage to people with pre-existing conditions, and to allow businesses and individuals to combine in purchasing pools to get better rates and to keep their insurance when they change jobs; administrative reforms to cut down on paperwork; and legal reforms that would reduce costs from awards in medical malpractice cases.
No 'mother ship'
"I think pieces of health care reform will go through," said Rep. Fred Grandy, an Iowa Republican who has been active on the issue for the House GOP. "But I don't think it will be the great mother ship of health care reform that the Clinton plan is."
Rep. David E. Bonior of Michigan, the House Democratic whip, says he is less concerned than many of his colleagues are about the role of Republicans in the health care debate.
"I think we're going to pass a comprehensive plan, and we're going to do it with a heavy vote," Mr. Bonior said.
"The Republicans can't afford to filibuster health care; the American people won't let them. I don't mean that to sound like a threat. I think bipartisan support on health care is very important. We're going to be working with them on this for decades ahead."
President Clinton's health care address will be carried on TV as follows:
* ABC: Live speech at 9 p.m., followed by Republican response. On "Nightline," at 11:30 p.m., Ted Koppel moderates reaction from Tampa, Fla.
* CBS: Live speech at 9, followed by Republican response, then a special edition of "48 Hours" at 10 p.m. with Dan Rather and Connie Chung interviewing administration figures, health care workers and citizens from CBS Washington studios. Included is ZTC a Rather interview with first lady Hillary Rodham Clinton.
* NBC: Live speech at 9, followed by Republican response, then a special edition of "Now" with Tom Brokaw and Katie Couric live from Temple University Hospital in Philadelphia. The program will focus on major points of the health-care proposal: availability, efficiency, choice and personal responsibility.
* Fox: Like other Fox stations across the country, local affiliate WBFF (Channel 45) will show the speech and Republican response on tape at midnight.
* PBS: A tape delay of "MacNeil/Lehrer NewsHour: President Clinton's Health Care Address" at 11 p.m. on Maryland Public Television (channels 22 and 67), with the full speech and response.
* CNN: Coverage begins at 8:30 with a half-hour preview special with Bernard Shaw and Judy Woodruff as hosts and including a panel discussion; Live coverage of speech at 9 p.m. followed by Republican response; a special "Larry King Live" on health at 10 p.m., with the host in a Chicago bowling alley and including an interview (from Washington) with Health and Human Services Secretary Donna E. Shalala.
* C-Span I & II: Live coverage of speech and Republican response at 9 p.m. On C-Span I, a preview program of live viewer call-ins at 8 p.m.
* Comedy Central: Live speech coverage at 9 p.m. Titled "Democracy In Action: The President's Address on Health Care Reform," coverage includes humorous graphics and "crawls" superimposed on the uninterrupted speech. (The channel promises such comedic coverage for every major presidential address.)