WASHINGTON -- At a time when most of the momentum around health care reform seems to be directed toward slowing down and trimming back the costs of the new insurance program, a consensus is quietly building for one expensive new benefit.
Home health care coverage for the elderly and disabled, which only recently seemed like a luxury Congress could not afford, is now given a reasonable chance of being included in some form in the version of the health care bill that comes up for a final vote this fall.
"I wouldn't have said that even two weeks ago," Sen. Russell Feingold, a Wisconsin Democrat who has made long-term care benefits a top priority in the health care debate, observed last week. "But it's been included in all of the bills that have come out of committees, even the most modest. Some of those approaches are really very good."
Other advocates have come to a similar conclusion, as congressional committees have nibbled around the edges of the long-term care benefit proposed by President Clinton but left the framework intact.
"I think this means we're going to get something included in both of the bills that go to the House and Senate," said John Rother, chief lobbyist for the American Association of Retired Persons. "Once it's there, I don't think people are going to want to vote to take it out."
All bets are off, though, if Congress rejects a comprehensive overhaul of America's health care system as proposed by Mr. Clinton, and chooses instead a minor program of insurance-market changes, such as the alternative recommended by Senate Republican leader Bob Dole of Kansas.
"Dole would just take from seniors in the form of Medicare and Medicaid cuts and give nothing back," said Patrick Burns, a spokesman for the Leadership Council on Aging Organizations, which plans to attack Mr. Dole's approach at a Washington news conference scheduled for today. "We say 'No thanks' to that."
The concept of helping Americans take care of disabled relatives at home or in community-based centers rather than nursing homes is almost universally popular in Congress. Many of the lawmakers are baby-boomers personally familiar with the difficulty of trying to care for aging parents or disabled offspring without sending them to nursing homes or facing financial ruin. At present, there is no Medicare coverage and little private insurance for home health care.
Influential lobbies are pushing hard for this benefit, which would help with the costs of adult day care, home health care aides and medical equipment. And there is no organized constituency fighting against it -- except perhaps for private insurance companies that would prefer to sell policies for nursing-home care.
Home health care appears to have become even a higher priority than prescription-drug benefits for many groups, and thus is given a better chance of being included in the final bill.
About half the population is expected to need home health care at some point, and almost no one has insurance to help with it now.
But the size and the extent of the home care program that survives remains a question that depends on how much money Congress is willing to raise through new taxes or cut from the Medicare and Medicaid programs.
"There are a lot of things Congress is going to want to be able to do that they just don't have the money for," said Thomas A. Scully, a former Bush administration budget official who is now lobbying for insurance companies and other interests on health care. "The employer mandate is going to be the key."
Mr. Clinton's proposal to require employers to help pay for their workers' health care benefits would provide the financial underpinnings of his health care reform program, which is intended to guarantee insurance coverage for all Americans. Supporters argue that it is vital. But it is also the most controversial aspect of his bill, and is particularly unpopular in the Senate.
The Senate Finance Committee, which rejected the employer "mandate" in its version of the bill, found a way to pay for a long-term care benefit through a complicated bookkeeping tactic.
But the committee's estimate that this system would raise $16.7 billion over five years has been questioned by the Congressional Budget Office. That technique won't survive the legislative process if the numbers don't add up.
In the House Ways and Means Committee, the home health care benefit was linked to a tobacco-tax increase. When the 60-cents-a-pack tobacco tax increase had to be reduced to 45 cents to pick up votes for the bill, the starting date for the home health care benefit was delayed to save money.
The Ways and Means bill now calls for a modest $3 billion program to begin in the year 2000 and reach a $10 billion annual total four years later. Mr. Clinton had originally proposed launching a $4.5 billion program beginning in 1996 that would reach an annual cost of $38 billion by fiscal 2003.
Senator Feingold hopes to persuade his colleagues to enact a more generous program than the Ways and Means bill, with the argument that it would save money for the government in the long run because home health care is cheaper than caring for people in nursing homes.
His home state of Wisconsin shaved $45 million off its Medicaid bill last year, in part by providing grants for home health care that enabled the poor, elderly and disabled to avoid the higher cost of nursing homes, where Medicaid pays all the bills.
But the total amount of money spent on a new national long-term care program would rise nonetheless as families, who would otherwise struggle on their own to care for ailing relatives, take advantage of the new home care benefits.
"It's a big number, but it's very cost-effective," Rep. Benjamin L. Cardin, a Baltimore Democrat who serves on the Ways and Means Committee, said of the potential cost of a new long-term-care benefit. "I think we will approve a very modest start to a home health care benefit. It's a big void in our health care system today."