WASHINGTON -- A proposal to guarantee health care for all Americans reached its first critical milestone last night, when a House subcommittee narrowly approved a rewrite of President Clinton's health care reform program.
The 6-5 party-line vote by the House Ways and Means Committee's health subcommittee was a shaky first step that nearly fell apart in a dispute over a financing provision that is likely to be changed later.
The action sent a plan for curing the nation's health care problems to the full Ways and Means Committee, whose chairman, Dan Rostenkowski, an Illinois Democrat, has promised to "begin at the beginning" in hopes of building a proposal with broader support.
The heavily edited draft approved by the subcommittee follows Mr. Clinton's lead in requiring employers to buy health insurance for their workers and in imposing cost controls by setting health care spending limits for each state.
But under the direction of the subcommittee chairman, Rep. Pete Stark, D-Calif., the measure would also create a new government-run Medicare program to insure the unemployed and would raise cigarette taxes by $1.25 a pack to help pay for it.
A compromise amendment dropped an unpopular 0.8 percent payroll tax that Mr. Stark had included in his bill. He replaced it with a series of new taxes and program cuts that many committee members consider even worse.
Rep. Gerald D. Kleczka of Wisconsin, one of the six Democrats whom Mr. Stark was counting on, said he developed "heartburn" when he saw that states like his -- where health benefits are more generous than average -- would be penalized by having to pay extra under the new amendment.
"I'm tempted to vote against this," he said. "If I could tell the people in Wisconsin this will be gone in August, that's one thing. But I have to go home again."
Mr. Stark said he doubted that any committee members were completely happy with the bill. "The question is, 'Do we have enough support to see the process moved forward?' " he said.
Much of the plan approved by the subcommittee is likely to be replaced farther down the legislative path.
But yesterday's approval was an important step in the long, rugged road toward achieving Mr. Clinton's goal of providing health insurance for all Americans.
Mr. Rostenkowski asserted last night that the subcommittee had "won an important battle in a legislative war that will be our focus for the remainder of this year."
"We are not oblivious to the difficulties," he said in a statement, "but we are cautiously optimistic that we can surmount them."
The plan approved by the subcommittee last night:
* Would require all employers to pay 80 percent of the cost of insuring their employees.
* Unlike the Clinton plan, would not force most Americans into health insurance purchasing alliances. The plan would let people keep the private health plans they have now.
* Unlike the Clinton plan, would not have the government subsidize small businesses.
* Would limit the growth of private and public health expenditures as an inducement to economize.
* Would limit the damages that can be awarded in medical malpractice cases.
Approval of the subcommittee draft came after two weeks of heated debate.
Yesterday, the panel's Republicans tried to embarrass the xTC Democrats by forcing them to vote on Mr. Clinton's original 1,342-page proposal.
Rep. Bill Thomas, a California Republican, said he put the Clinton plan up for a vote because he knew none of the Democrats would propose it.
Many of the features in Mr. Clinton's bill, including his proposal for a nationwide network of regional health alliances through which all Americans would be required to buy their insurance, are unpopular with Democrats as well as Republicans.
So all seven subcommittee Democrats abstained when the vote was called on the Clinton bill. The four Republicans voted "no."
"The Republicans are just playing a political game," said Rep. Benjamin L. Cardin, a Baltimore Democrat. He called the Stark plan "an evolution" from the Clinton bill. "We have improved upon it."
Before approving its own version of health care reform, the subcommittee cast largely symbolic votes to reject most of the major alternatives being discussed in Congress.
One of the most popular among congressional moderates, a so-called managed-care bill sponsored in the House by Rep. Jim Cooper, the Tennessee Democrat, was rejected, 6-5. It is designed to encourage competition in the health industry -- and thus lower costs -- through tax incentives.
Mr. Stark complained that it would "herd all Americans" into the cheapest of managed care programs, known as health maintenance organizations, or HMOs, by imposing tax penalties on employers that want to provide more generous benefits.
Rep. Jim McDermott, the Washington Democrat who is the chief advocate of a Canadian-style health program that would cover all Americans, called the Cooper bill "the most radical social engineering program."
The subcommittee also rejected Mr. McDermott's plan .