WASHINGTON — Senior White House aides outlined for the first time Friday the overall structure that they envision for a massive overhaul of the way in which Americans get and pay for medical care.
Although many major decisions still have not been made--most notably how much the national health care plan will cost and how it will be paid for--the description offered by three senior Administration officials provides the clearest information so far on where President Clinton and his advisers are heading as they begin making decisions on the shape of the plan.
The three officials spoke to a group of reporters on condition that they not be named--part of an Administration effort to begin selling the plan by describing key elements to the public in advance of the final decisions.
Clinton intends to make the final decisions in the next several weeks and unveil the reform plan in late May, aides said. Decisions about which new taxes will be proposed to finance the plan probably will be made last, once all of the other choices affecting the cost of the new system have been made, one of the senior officials said.
In a significant departure from previous descriptions of the new plan, officials stressed that it would preserve a major role for traditional "fee-for-service" medicine, in which doctors are paid separately for the procedures they perform.
Under the proposed new system, every American would be insured and guaranteed access to a nationally mandated package of benefits, probably determined by a national health care board acting within overall guidelines set by law.
The universal coverage would be phased in over a period of years, with the length of the phase-in period still the subject of intense debate within the Administration.
"This is a major change affecting one-seventh of the economy," the senior official said. "You can't turn that on a dime." On the other hand, another official said, too lengthy a phase-in period could be "a nightmare" of conflicting coverage systems.
A central element of the Administration's plan is a series of what officials call "health alliances" that would administer the health care system. In sparsely populated states such as Wyoming or North Dakota one health alliance might cover all residents. California, by contrast, would probably be divided into five to 10 geographical areas, each served by a single health alliance, a senior official said. The areas served by an alliance would be large--the entire Los Angeles metropolitan region would probably be covered by a single alliance, for example--to ensure that territories could not be segregated by race or economic status.
Within the territory served by a health alliance, all residents would be able to choose among the same health insurance plans. For any one plan, all people of the same age would pay the same insurance premium, regardless of current status or past medical history.
By contrast with the current system, insurance plans would be required to take all comers regardless of medical history.
"You cannot be dropped by a plan and they have to take you," a senior official said.
In some states, particularly those that are sparsely populated and have too few doctors to establish an efficient network, the state may set up its own health plan--in effect replicating the "single payer" system of a country like Canada on a statewide basis. In most states, however, insurance will be left to private companies.
The overall idea, said one senior official is that the "government will set parameters and offer certain guarantees" of coverage and quality but "the delivery of health care remains largely in private hands."
The government would also provide incentives to expand access to health care in inner cities and rural areas that are now underserved.
Older people, who use health services more than the young and who tend to have higher incomes, may be required to pay somewhat higher premiums than younger individuals. Those over 65 will continue to be covered by Medicare, but Medicaid (Medi-Cal in California) would disappear as low-income people are given the same choice of insurance plans offered to all others in their region.
Some plans probably would offer benefits that exceed the nationally mandated package in return for a somewhat higher premium, a senior official said. Administration planners, the official said, are trying to "strike a balance" that would "maximize consumer choice" on the one hand but on the other hand "not allow a two-tier system to develop" in which the wealthy would choose some plans while the poor would be shunted into others.
Individuals and employers would split the premiums for workers' health insurance. While no decision has been made on how the costs will be divided, employers are expected to pay more than workers.