"Please Help Us"

By GEORGE J. CHURCH

At last, all the details are on paper. To be exact, on 1,342 pages of paper that President Clinton hand-carried to Capitol Hill. Congressman Pete Stark, a California Democrat, said the next day that he had "stayed up to 4 a.m. but couldn't finish getting through" the proposed Health Security Act he had agreed to co-sponsor. Clinton himself rather plaintively told a Baltimore audience that "my brain aches" from studying the details of his own plan.

Even members of the Cabinet seemed a bit addled. On the morning Secretary of Health and Human Services Donna Shalala told a Senate committee the bill sets no global budget -- that is, no limit on total national spending for health care -- Treasury Secretary Lloyd Bentsen and Labor Secretary Robert Reich separately testified that it does. (In fact, there is nothing called a global budget, but the Administration hopes limits on insurance-premium increases will have the same effect.)

For all the complexity and confusion, though, delivery of the draft bill marked what Budget Director Leon Panetta, borrowing a line from Winston Churchill, called "the end of the beginning" in the great national-health- care debate. For months that debate has focused on ideas, generalities, trial balloons, leaked outlines. Now it can zero in on the specifications of an actual draft bill. Not necessarily one bearing much resemblance to what Congress may eventually pass, however. Said Senate Republican leader Robert Dole: "I'm willing to wager that the final product will be considerably different from any bill that has been proposed to date" -- including Clinton's and five alternates offered by legislators.

Certainly the President is under no illusion that his bill is likely to sail through with few changes. The latest poll for TIME by Yankelovich Partners Inc. confirms what nearly all observers had sensed: his plan has suffered a serious loss of support since he outlined it in a stirring speech to Congress on Sept. 22. The next day, 57% of those polled generally approved, but last week only 43% did; 36% were opposed, vs. 31% five weeks earlier, and the proportion of those "not sure" increased from 12% to 21%. Responses to some more detailed questions indicated worse trouble: 36% thought increased federal involvement in the U.S. health-care system would make that system worse, vs. 33% who foresaw improvement (given the margin of sampling error, that amounts to a statistical tie). More striking still, 29% thought the plan would leave them and their families "worse off," vs. only 20% who expected to be "better off"; 48% anticipated little change.

Trying to reverse this trend, Clinton struck notes ranging from passionate to pleading. Presenting the bill at a ceremony in Statuary Hall at the Capitol, Clinton began waving his arms and banging the lectern, first with a forefinger and then with a fist, as he slid into an ad-lib riff on the necessity for reform: the U.S., he cried, is "choking on a health-care system that -- is -- not -- working." The day after, in a speech to medical students and professors at Johns Hopkins University in Baltimore, Clinton sounded oddly supplicating: "Please help us," he implored.

More to the point, the President and Hillary Rodham Clinton, head of the task force that produced the plan, repeatedly disavowed any "pride of authorship" in its details. The President did proclaim that he would sign only a law that "guarantees every single American a comprehensive package of health benefits . . . that can never be taken away." Some listeners inferred that he was throwing almost everything else open to compromise. Administration aides denied they were "walking away" from any major elements of the plan, but would not specify what is negotiable and what is not.

In a sense, the compromising started while the bill was still being written. As presented in Statuary Hall, it contained many changes from a preliminary draft that had leaked seven weeks earlier. Most were minor: at a briefing for journalists, one Administration aide even fretted that "we've got 200 reporters here and no story." That, however, was an exaggeration. Though they left the main outlines of the Administration's approach intact, the changes did signal White House willingness to make adjustments to respond to specific criticisms.

A number of changes were designed to counter fears that the Administration was underestimating the costs of its reforms and that it could not or would not keep those costs from spiraling out of control. Among other things, it increased its estimate of annual inflation from 2.7% to 3.5%, lowered its estimate of how much it could save on Medicaid expenditures from an original $114 billion to $65 billion, and created a financial "cushion" to provide for unanticipated expenditures. As a consequence, it now figures that its reforms will take only a $58 billion bite out of the federal deficit in the five years ending in 2000, vs. $91 billion projected earlier. Most important, and most controversial, was a complex system of premium and subsidy caps. Clinton's bill would require both employers and individuals to pay for health insurance, but a family's premiums could not exceed 3.9% of income. Federal subsidies would be provided for both individuals and companies that could not afford it, and those subsidies would be extended to some companies with as many as 75 workers, vs. 50 or fewer initially. But the subsidies would also be capped, at annual figures adding up to no more than $165 billion between 1995 and 2000.

Suppose more was required? Chances are it will never happen, say Administration aides; the cap is a psychological sop to conservatives who are worried that the subsidies would become an open-ended drain on the Treasury. Officially, though, the President and Congress would have to decide whether or not to put up more money. That alarmed some liberals, who feared that the feds would simply let some people go without insurance that they could buy only if they were given additional subsidy, and that the Administration would thus renege on its promise of universal coverage. More likely the caps would turn out to be unenforceable, like those the succession of Gramm-Rudman acts sought to impose on federal spending.

Other changes aimed at loosening what many critics had charged was an excess of bureaucratic regulation. States were given an extra year, until Jan. 1, 1998, to set up the health-care alliances the plan contemplates. If a state opts instead for a single-payer system under which the government becomes sole insurer and pays all doctor and hospital bills, the revised bill simplifies the administrative procedures that state must go through. To ease fears that the Administration will restrict patients' choice of doctors, the final bill provides that even health maintenance organizations must allow members to consult doctors who are not in the HMO's network, though patients would have to pay more of the cost.

The Administration also spelled out some further details of its plans. Testifying before the Senate Finance Committee, Shalala said 40% of people who now have medical insurance would have to pay more for coverage -- about $100 to $500 a year more. Committee chairman Daniel Patrick Moynihan estimated that would be 100 million people; Shalala did not contradict him, but another Administration official said the number would be about 71 million. Whatever the number, said Shalala, they would be paying a bargain price for the increased security of knowing that their insurance could never be canceled or reduced.

None of which seemed to make much impression on the plan's many opponents. Right now, says John Motley, vice president for governmental relations of the National Federation of Independent Business, Clinton "doesn't have 100 votes in the House or 30 in the Senate." His view is undoubtedly colored by the bitter opposition of his organization to a bill its small-business members fear will force them to pay more than they can afford to insure their workers. (The Administration's view is that the subsidies will prevent this from happening.) But it is a fact that the Clinton bill's list of sponsors -- fewer than 50 Democrats in the House and 31 Senators, including a lone Republican, Jim Jeffords of Vermont -- compares unfavorably with the 89 House Democrats sponsoring a bill to institute a single-payer system for the entire country, or the 50-odd bipartisan sponsors of the most popular competing House bill.

Two major factors are in Clinton's favor. Politicians almost unanimously agree that public sentiment so strongly favors some kind of health-care reform that many Congress members dare not run for re-election in 1994 without having voted to enact any. And if Clinton's plan has yet to command a majority, the opposition has not yet coalesced behind any alternative. Those proposed run the gamut from a conservative Republicans' bill that would merely provide tax credits for people buying health insurance, to the liberal Democrats' single- payer plan; neither has a chance of passing.

There are some signs, however, that bipartisan moderates may come together around some variation of a House bill introduced by Jim Cooper, a Tennessee Democrat, and Fred Grandy, an Iowa Republican. Cooper describes his bill as "Clinton Lite": less costly, less mandatory, less bureaucratic. Clintonites reply that it also would not cover all of the 37 million people now uninsured. Nonetheless, staff members for Cooper and Senator John Breaux, a Louisiana Democrat, have begun negotiations with aides to Dole and Republican Senator John Chafee of Rhode Island to see whether they can blend their efforts into a single, bipartisan, both-chambers bill.

Hillary Clinton, bravely venturing to Kansas City, Missouri, for a "health summit" organized by Dole at which she spoke along with no fewer than seven Republican Senators, gave a glimpse of the White House counterstrategy. She pointedly complimented Chafee for including universal coverage in his bill. The implication: the Administration will seek to get that established as the prime goal and convert the dispute into a mere debate about the best way to achieve it -- an argument Clinton's aides think they can win. The First Lady, however, drew only tepid applause, in sharp contrast to the raves inspired by her congressional testimony a month earlier, an indication perhaps of how much the Administration's support has slipped. In any case, Clinton's lieutenants are prepared to make additional modifications in their plan to win votes away from the alternatives. "We're hoping to peel off some people from the left, some from the center and some from the center-right," says one strategist, who writes off only the most conservative Republicans as unwooable.

The Clinton bill is so complex that congressional leaders will need a week to 10 days merely to parcel out its various parts among the many committees waiting to begin hearings. The earliest anybody expects an actual bill to pass is next August, and it could be next fall. The outlook is still for something to pass, but it will be a long time before there is any solid clue as to what.

CHART: NOT AVAILABLE

CREDIT: NO CREDIT

CAPTION: THE TIMETABLE FOR PRESIDENT CLINTON'S HEALTH-CARE PLAN

CHART: NOT AVAILABLE

CREDIT: From a telephone poll of 500 adult Americans taken for TIME/CNN on Oct. 28 by Yankelovich Partners Inc. Sampling error is plus or minus 4.5%.

CAPTION: In general, do you favor or oppose President Clinton's health-care program?

From what you know of the health-care reforms, do you think your medical payments will:

And do you think, in general, you and your family will be:

With reporting by James Carney, Julie Johnson and Dick Thompson/ Washingto n