NEW YORK -- While President Clinton's sweeping proposals would extend health care equally to all Americans, consumers and businesses in and around older urban areas are likely to find themselves paying substantially higher premiums for coverage than their counterparts elsewhere, and in many cases even higher than today.
At its core, the Clinton plan would create a web of regional "health alliances" to pool the purchasing power of consumers and negotiate on their behalf for lower prices for health insurance.
The Clinton system would not necessarily produce new costs -- indeed it is intended to operate more efficiently than what Americans have now -- but it will almost certainly reshuffle the deck in who has to pay the costs of medical care.
The states, not Washington, are to create these new purchasing pools and decide their boundaries. What is critical, though, is that the regional alliances that include big cities with costly health care burdens will be forced to charge their residents more than those that do not.
Billions of dollars are at stake. The outcome, economists and health analysts predict, could be a free-for-all over medical costs, pitting cities against suburbs, rich versus poor, region against region.
"How you draw the boundaries of these alliances will determine the distribution of risk and, in many respects, the distribution of costs," said Lawrence Brown, a professor of public health at Columbia University. "All sorts of hell would break loose once you throw this political football on the field."
No one knows how expensive health care would be under the new system. But the White House itself acknowledges those charges would be higher in many urban areas, particularly in the Northeast. And, depending on how the plan is carried out, health care protection may vary in cost by 25 percent or more -- even in areas close to each other.
Administration planners point out that health care costs are already higher in most cities than in surrounding suburbs and rural areas. The Clinton plan would allow states, if they chose to, to redistribute those burdens more equitably, but it would also permit even wider disparities.
"These are decisions we are leaving up to the states," said Richard Kronick, a White House official who helped develop the health plan.
To make the alliances effective, the sweeping health care revision proposed by the White House would introduce, in every region of the nation, the insurance system known as community rating. That system is widely applauded by health experts, whatever their position on other reforms.
For most parts of the country, that would be a dramatic departure. As things stand, insurance companies generally charge each individual or family in a given group the same premium. But because groups can be as small as a single business, it may cost a lot more to insure one group than another. Indeed, in a small group one expensive condition like an AIDS case or a premature birth can sharply push up the charges for everyone.
What you pay would no longer depend so much on what you get. Instead, it would be determined even more by where you live and who you are grouped with.
Many expensive health problems -- AIDS, drug addiction, poverty -- are concentrated in cities. The Clinton program would shift much of the cost that is now borne by federal taxpayers across the nation to ratepayers within each alliance.
At present, Medicaid pays medical bills for millions of poor people.
Under the Clinton plan, the poor and disabled would become full-fledged members of the health alliances, and their costs would go into the pool that every member shares.
The Clinton health plan would encourage states to draw the alliance borders along the lines of what the Census Bureau defines as a Consolidated Metropolitan Statistical Area.
"I think there is a strong argument for having just one statewide alliance," said Dr. Bruce Siegel, New Jersey's commissioner of health. "But I imagine you would end up with at least three separate alliances, simply because different parts of the state will insist upon it."