WASHINGTON -- With its formal arrival on Capitol Hill yesterday, President Clinton's health care reform proposal began a months-long struggle for survival against at least five competing alternatives -- each with its own legion of passionate advocates in Congress.
The biggest challenge is not expected to come from those who would do nothing or just a little.
Instead it would come from a growing centrist coalition that advocates reform almost as sweeping as the president but without the two most controversial elements of his plan: requiring large employers to pay 80 percent of workers' insurance premiums and setting cost limits that critics fear could lead to rationing.
The centrists propose to reform health care mostly by encouraging greater competition among doctors, hospitals and other health providers.
"I think that's going to look very attractive to people who would prefer to phase-in these major changes," said Rep. Benjamin L. Cardin, a Baltimore Democrat who favors the Clinton bill. "What scares me is that we'll only go part-way and not get back to it for another 30 years."
President Clinton revealed his concern about the appeal of a half-way approach yesterday when he told the lawmakers he wouldn't sign a bill that fails to guarantee a "comprehensive package of health care benefits" for everyone in the nation.
Administration officials claim there is no practical way to achieve universal coverage unless employers or the government pays for it.
But leaders of the centrist coalition that embraces both parties in Congress say they expect the president to agree on a compromise that falls short of universal coverage by 1998 financed largely by employers.
"He's already backed off from his original target date of 1996," observed Sen. John H. Chafee of Rhode Island, leader of a faction of moderate Senate Republicans who want to see savings from competition produced first before they expand health care benefits.
"We would reach universal coverage by 2,000. I can't see two more years is the end of the world," he says.
Mr. Chafee is negotiating with Sen. John B. Breaux of Louisiana and Rep. Jim Cooper of Tennessee, Democratic co-sponsors of another moderate plan with bipartisan support, with the goal of merging their forces into a single block.
Their chief goal will be to force Mr. Clinton into delaying or minimizing his requirement that employers pick up 80 percent of workers' premiums. They also will resist the premium caps or other limits on health costs that they fear will lead to rationing of care.
Debate over these and other issues will be conducted primarily in five major House and Senate committees in the coming months, but legislative leaders haven't yet worked a strategy for brokering the final deal.
Sen. George J. Mitchell, D-Maine, the majority leader, said he is confident the Congress will pass a bill that provides for universal coverage involving a requirement that employers pay a portion of premiums.
"But the date for when it would take effect is obviously up for discussion," Mr. Mitchell said.
Although the Democratic leaders of both houses are supporting the Clinton bill, no one expects it to be enacted without major changes, many sought by these very leaders themselves.
In fact, administration officials were so eager to boost the number of their co-sponsors to look strong against popular alternatives, they signed on lawmakers like Rep. Fortney H. "Pete" Stark, a California Democrat who is an outspoken advocate of a government-run, Canadian-style plan and hasn't abandoned that view.
First Lady Hillary Rodham Clinton, chief architect of the administration proposal, acknowledged it would serve primarily as a "framework" for the coming months of debate.
But the scores of adjustments likely to be made to the 1,300-page document are considered certain to slow it down, trim it back, make it less generous, less ambitious and less controversial, lawmakers predicted.
Rep. Henry A. Waxman, a California Democrat who is considered a leading expert on health care in the House and who would prefer an even a bolder plan than Mr. Clinton has offered, expects the president's plan to be the "high water mark" on benefits, coverage and cost controls, an aide to the congressman said.
Thus, Mr. Waxman thought it was strategically unwise for Mr. Clinton to compromise so soon with conservative lawmakers by promising a ceiling on government subsidies to small businesses and low-income people who can't afford to pay their premiums.
That change has already undermined Mr. Clinton's promise of "health security for all," Mr. Waxman said in an interview.
Although there are now six different proposals for reforming health care in Congress, the real competition will be waged among those at the center of the political spectrum.
Conservative Republicans are not expected to be major players in the debate.
They have been isolated by GOP colleagues, such as Mr. Chafee and Rep. Fred Grandy of Iowa, who are working toward bi-partisan compromises in the center.
Those on the far left of the spectrum, such as Mr. Stark and the 89 House Democrats who also favor a Canadian-style government-run plan, will wind up serving mostly as ballast to TC keep the Clinton proposal from wandering too far to the right.
CAPITOL HILL'S HEALTH REFORM FACTIONS
With the delivery of President Clinton's health reform legislation yesterday, Congress begins what is expected to be a year-long debate on reshaping the country's health care system. Here is the line-up of the six political factions jockeying for position on the health care reform debate:
Canadian-style single payer
This group includes 89 Democrats in the House and at least five in the Senate who are pushing for a comprehensive, federally-run program, financed by payroll taxes on employers. Chief sponsors are Rep. Jim McDermott and Sen. Paul Wellstone, but Rep. Fortney H. "Pete" Stark, the California Democrat who chairs the House Ways and Means subcommittee on health, is a leading advocate. The Democratic leadership in both houses and key committee chairmen, including Sneate Finance Committee Chairman Daniel P. Moynihan, Senate Labor and Human Resources Edward M. Kennedy, House Ways and Means Chairman Dan Rostenkowksi and House Energy and Commerce Chairman John D. Dingell, back the central elements of the president's plan to guarantee a comprehensive package of health benefits to all Americans. Employers would pay at least 80 percent of workers' premiums, with workers paying the rest. Regional health alliances would bargain with private insurers on behalf of consumers. Costs would be controlled by imposing limits on insurance premiums.
The group of centrists backing this plan come from both political parties and both houses of Congress. Democratic Rep. Jim Cooper of Tennessee and Republican Rep. Fred Grandy of Iowa are the lead sponsors in the House. In the Senate, Democrat John B. Breaux of Louisiana and Minnesota Republican Dave Durenberger are offering a nearly identical plan. It relies on so-called managed competition between health-care providers to lower costs and make health care more affordable without cost controls. A national board would also establish a benefits package, and states would create purchasing cooperatives for small business. Republican Sen. John Chafee of Rhode Island is the chief architect of this alternative to the Clinton plan, which is backed by most of the Senate's moderate Republicans, and Republican Leader Robert J. Dole of Kansas. It would require all individuals to obtain health insurance, but provides no means to pay for it beyond lowering costs through increased competition. No cost controls would be imposed. A national board would create a standard benefits package, and states would establish purchasing cooperatives for small business and individuals. Favored by conservative Republican senators, this proposal, sponsored by Phil Gramm of Texas would embrace some of of the market and legal reforms called for by the broader plans, but impose only minimal new regulation. Employers would be required to offer at least three choices of health insurance plan, but not be bound to pay for them.
This plan offered by House Republican Leader Robert H. Michel is also a conservative approach that requires employers to offer at least one insurance plan and a tax-free medical savings account. A basic benefits package would be determined by the National Association of Insurance commissions. It calls for one of the toughest approaches on legal reform, including a $250,000 cap on pain and suffering damages and a 20 percent limit fees paid to lawyers, who now normally collect one-third.