WASHINGTON -- Women, who probably had the most to gain from President Clinton's proposed overhaul of the health care system, may now have the most to lose as Congress moves to shrink and delay the program.
Women's health care advocates, who once viewed Mr. Clinton's proposal as a chance to make enormous strides on abortion rights, preventive services and direct access to insurance for the largest segment of the adult population that is without it, now fear they could lose ground in all these areas.
So much controversy has developed over how to finance reform that "a squeamish, incremental approach" appears to be taking hold of the legislative process, Pamela J. Maraldo, president of -- the Planned Parenthood Federation of America, a leader in abortion rights, complained yesterday. "We want to make sure coverage isn't lost."
A gradual, voluntary approach that fails to provide everyone with comprehensive coverage will do little to bring Pap smears, mammogram screenings and other preventive services within reach of working-class women who cannot afford them today.
In fact, critics say, a go-slow approach to reform could drive up insurance premiums, putting preventive services even further out ofreach for many.
As the 10-month-old health care reform debate moves later this month to the full House and Senate, a battle over abortion rights has long been expected.
It appears to be one of a handful of issues on which the success or failure of the entire legislation could turn.
But as important as the abortion cause is to women's advocates, it is secondary to the more fundamental question of whether Congress can produce a measure that meets Mr. Clinton's goal of guaranteed health care for all Americans.
"It's really hard to figure out abortion strategy when you don't know what's going to happen to the priority concern of universal coverage," said Andrea Camp, a spokeswoman for Rep. Patricia Schroeder, a Colorado Democrat who has been a leader on women's issues in Congress.
"Universal coverage" is the underpinning that would open the insurance market to women who are disproportionately poor, jobless, work part time, have no company-paid insurance, or who are covered by a spouse's policy over which they have no control.
Without some version of Mr. Clinton's proposal that employers be required to buy insurance for their workers and a new government program to subsidize the working poor, many of the 12 million women now without health insurance are unlikely to get it.
Republican lawmakers argue that even without mandates requiring insurance coverage, more people can get policies because of lower costs that will result from greater competition and because of market reforms to bar insurance companies from denying coverage for pre-existing conditions, such as breast cancer.
Won't lower costs
But industry lobbyists contend that those reforms won't lower costsunless premiums can be spread across the population.
For example, they say, if an insurance company accepts the risk of a woman diagnosed with breast cancer, all others in the plan will have to pay more.
As premiums rise to absorb those costs, industry lobbyists say, young, healthy people who must buy insurance on their own will drop out, shrinking the pool of payers. Premiums will rise further, ultimately raising the costs beyond the reach of most of the middle class.
Female lawmakers on three of the four congressional committees that produced versions of the bill, including Sen. Barbara A. Mikulski, D-Md., worked to meet women's health needs.
Under most versions of the bill, preventive services, such as regular Pap smears and mammogram screenings, are included in the basic benefit package that must be offered.
But without universal coverage, Dr. Maraldo of Planned Parenthood said, those services still won't be available to most women who can't afford them now.
If Congress signals to employers that providing health insurance to workers is not expected of them, other women could lose the coverage they have now.
Women have more to lose
"Women have a lot more to lose from this than they realize," said Alice Weiss, a program analyst for the Campaign for Women's Health, a grass-roots advocacy group.
Thus, women's rights groups are in the forefront of the crusade Hillary Rodham Clinton unleashed two weeks ago, when she urged the strongest supporters of her husband's bill to put aside parochial concerns and focus on assuring coverage for all.
As House and Senate leaders combine their committee products into two bills that will be considered by their respective 'u chambers, Planned Parenthood and other women's advocacy groups have joined the administration in trying to alert the public to broader issues at stake behind the debate over financing.
For lawmakers who consider abortion rights a bottom-line issue, though, the politics of the next few weeks of frantic deal-making are likely to be tricky.
In the trade-offs to secure enough votes to enact legislation that achieves universal coverage, some concession to the abortion opponents will probably be required.
Few swing votes
In most cases, lawmakers who oppose abortion are also those who have been reluctant to endorse a measure that would provide universal coverage.
But there are a few potential swing votes on the issue in both the House and the Senate.
One of the most crucial may be Sen. John C. Danforth, the MissouriRepublican who helped shape the bipartisan compromise that allowed the Senate Finance Committee to produce a health care reform bill before Congress adjourned for its July 4th recess.
Mr. Danforth scored the first major assault on abortion rights protections that Mr. Clinton included in his bill.
The Finance Committee rejected a move to drop abortion from the basic benefit package but allowed employers to refuse to offer it, thus potentially forcing their workers to anticipate the need for such coverage and buy it elsewhere.
Douglas Johnson, chief lobbyist for National Right to Life, a leader in the fight against abortions, believes Senate Majority Leader George J. Mitchell will drop the Danforth amendment from the measure he brings to the Senate this month.
But even tougher anti-abortion amendments are sure to be offered, and filibusters have been threatened by legislators on both sides of the issue.
Compromising on abortion is especially difficult because maintaining the status quo -- often a way out in Congress -- is probably impossible if the health care system is restructured.
"I can tell you, Pat, for one, is not going to vote for anything that sets women back," Ms. Camp said of Mrs. Schroeder, who is now circulating a letter signed by 59 of her colleagues saying more or less the same thing.