WASHINGTON -- If President Clinton's health reform plan becomes law, millions of Americans may begin to hear a word to which they're unaccustomed at the doctor's office: No.
Mr. Clinton would force health plans -- groups of insurers, doctors and hospitals -- to live under tight budgets, with limits on the premiums that people would be charged for health care.
Administration officials strongly deny that any kind of rationing would result. But many experts believe that the pressure on health plans to control costs would force them to refuse patients access to some tests and treatments.
A person with an ailing shoulder might be denied an $800 magnetic resonance imaging (MRI) diagnostic test, for example. Elderly people in ill health might be ruled ineligible for some life-extending procedures on the grounds that the treatment for them is not "cost-effective." Patients might experience longer waits to see specialists.
"I think what's becoming evident is that there will be rationing of some kind or another -- there has to be," said Daniel Callahan, director of the Hastings Center, a New York think tank that specializes in ethical issues in medicine and science. "It could get rather controversial."
Opponents of the Clinton plan are already seizing on rationing in the battle for public opinion.
A representative of the Health Insurance Association of America, a group of insurers opposed to premium limits, told lawmakers last week that the plan would lead to extensive rationing "because in order to control costs you must control volume as well as price."
Rationing could be a potent issue with a majority of Americans, who are already well-insured and unaccustomed to restrictions on seeing specialists or getting tests.
When asked whether rising costs would be an acceptable reason to restrict treatment, a large majority of people disagreed, according to a Gallup Poll last October for the Employee Benefit Research Institute. This survey, one of the most extensive on the issue of rationing, found that 77 percent of respondents believe the way to control costs is to "cut waste, high profits and fraud in medicine."
Aware of public sentiment, the administration takes the same tack, arguing that its plan could cut $200 billion in waste and inefficiency without undermining patient care. The plan would guarantee a basic benefits package to all Americans and control costs by imposing a national budget on health care spending, and by restricting annual increases in insurance premiums.
During testimony to Congress, first lady Hillary Rodham Clinton asserted that the insurance premium caps wouldn't lead to rationing but would eliminate waste and reduce costs.
Cheaper care is not worse care, she said. "There is no discernible difference in quality between high-priced and moderately priced care."
No one questions the existence of waste. Studies document the overuse of technologies such as the MRI test and surgical procedures such as coronary bypasses. Joshua M. Wiener, an economist at the Brookings Institution who writes extensively about health care, notes that a new study shows that routine sonograms during pregnancy aren't very helpful in ensuring fetal health.
"People do not fully appreciate the extent to which the practice of medicine is an art rather than a science," Mr. Wiener said. "Much of what doctors do doesn't have any strong scientific evidence to support it."
But Mr. Wiener is among a legion of economists who strongly doubt that the president can achieve his cost-cutting objectives without forcing some limits on services. By the year 2000, Mr. Clinton would reduce the rate of health care spending increases, now 9 percent a year, to close to the 3 percent general inflation rate.
The White House can't easily dismiss such charges because so many credible sources say the same thing. A report by the Congressional Budget Office on Sept. 17 warned that premium caps could result in restricted access to new medical technology and the elimination of "some useful services."
But Mr. Callahan and other health care analysts believe the rationing issue is misunderstood. They observe that the present system rations care, often on the basis of income. And they say rationing -- budgeting of resources -- is necessary if the White House is to achieve its goal of universal coverage.
"There would be certain things denied [as] useless or futile," Mr. Callahan said. He used the example of "Baby K," the Virginia girl born last year with most of her brain missing. Although hospital officials wanted to end life-extending treatment, her mother obtained a federal court order requiring such treatment.
Mr. Callahan also predicts more rigid controls on expensive medical procedures that aren't likely to succeed.
Such controls come up repeatedly as Clinton administration officials seek to defend their plan.
Lawmakers raised this question with Mrs. Clinton during her recent testimony to Congress, asking about cases such as the Siamese twins separated in Pennsylvania at enormous cost, despite the knowledge that one would definitely die and the other probably would. So far, the surviving twin has beaten the odds.
Mrs. Clinton wouldn't respond specifically but said people should not be "denied treatment for any reason other than it is not appropriate -- will not enhance or save the quality of life."
At a town meeting in Tampa, Fla., on Sept. 24, Mr. Clinton assured a woman who had just been discharged from a hospital that under his plan, her doctor would decide when she was ready to go home rather than her insurance plan.
But Mrs. Clinton, who helped write the president's plan, gave a much different answer when she told a Senate committee the following week that "there will not only continue to be a role for insurance companies in managing and delivering care, but we anticipate that it may even be an expanded role. . . ."
That concerns Gail Shearer, manager of policy analysis at Consumers Union, publisher of Consumer Reports. "We're worried about it because insurance companies are accountable to their shareholders. . . ."
Many analysts say the rationing issue must be put into perspective.
"I think it's important to establish that we already have rationing," said Karen Rothenberg, director of the law and health program ** at the University of Maryland's School of Law. "It's just that we haven't had any formalized debate in this country about the choices, except maybe in Oregon."
Oregon has the only explicit rationing system in the country. Determined to make better use of the money spent on the Medicaid program for the poor, Oregon officials received permission from the Clinton administration this year to create a list of priority services. That way, more people could receive preventive and primary care, but fewer would receive transplants or other budget-busting, life-prolonging treatments.
Although such rationing is not done so openly elsewhere, the poor generally are victims of it, say Ms. Rothenberg and others. Poor, uninsured people who don't quite qualify for Medicaid get less care than the more affluent.
The middle class also receives rationed care, although few Americans recognize it as such. Employer-based health plans routinely place limits on services -- the number of times you can see a psychiatrist, for example -- and on reimbursement.
Viewed this way, the fear that Mr. Clinton's plan would result in rationing should be weighed against what would happen if no plan is enacted by Congress, Ms. Shearer suggests. "If Congress and the administration just stand by as health care costs continue to spiral up to 22 percent of GDP [gross domestic product], then we're going to be in such a crisis situation that rationing will be the rule, not the exception," she said.