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U.S. Cautiously Awaits Clinton Health Program


WASHINGTON — On Wednesday, in a speech before a joint session of Congress, President Clinton will formally ask the nation to embrace an idea spurned for more than a century: comprehensive, government-regulated medical insurance for every man, woman and child in the land.

Rich and poor, young and old, sick and well, the employed and the jobless--all will be insured if Congress accepts the President's approach. With the plan, health care could become a right, not a privilege.

Yet in recent weeks, as the broad outlines of Clinton's program have leaked out, many Americans could be pardoned for beginning to wonder what in the world is in it for them. After all, by the Administration's own admission, the plan will bring new taxes and government regulations, brigades of newly commissioned bureaucrats and unparalleled change and confusion.

For the vast majority who are now insured, Clinton's plan promises long-term medical security even for those who lose their jobs. But it could also mean higher out-of-pocket costs, the need to select a new doctor and, in effect, some rationing of health care.

For the 37 million Americans without insurance, Clinton's program offers a generous package of benefits at the going rate without regard to individuals' medical history. But young and healthy people will be called on to buy insurance whether they want it or not.

For employers whose spending for employee health insurance is out of control, the plan promises to put on the brakes. But employers that spend little or nothing for this purpose will face a new obligation to offer health insurance to all workers.

And as for the $900-billion-a-year health care industry, it faces less freedom and more regimentation.

Doctors' decisions about how to treat individual patients will be tightly hedged--first by national guidelines and the decisions of distant bureaucrats, then by considerations of cost and economics. Many insurers, unable to adapt, are likely to be forced out of business.

Nor are the alternatives to Clinton's approach free of blemishes.

The Canadian-style system favored by some liberal Democrats would bring even more government bureaucracy and control. The free-market solutions put forth by Republicans and conservative Democrats are not certain to control costs.

Under these circumstances, why is there such a rush to "reform" the present system at all? Why is Clinton determined to push his health plan at a time when his political underpinnings are already shaky? Why would Congress, itself living on borrowed time as far as most voters are concerned, consider approving one of the most far-reaching social changes of our time?

The answer is that the system is collapsing. It has been collapsing for a long time.

THE PAST: A Heavy Burden

The present system, born during World War II when companies began offering health insurance as a lure for scarce defense workers, is a product of a simpler time, a dinosaur increasingly hard-pressed to survive.

Fifty years ago the American population was younger. Scratching its way up from the Great Depression, its expectations were lower. Medical science was almost primitive by today's standards: Antibiotics and other wonder drugs did not exist; babies still died of whooping cough and diphtheria; simple pneumonia often carried away the elderly. There were no CAT scans or MRIs, no coronary bypass operations or cataract surgery, no liver transplants or hip joint replacements.

When President Franklin D. Roosevelt offered legislation that would have established compulsory national health insurance financed by a payroll tax, the plan--like many others that followed it--was ridiculed to death by the medical, political and business Establishments.

"It was viewed as a radical concept in the extreme," recalls Rep. John D. Dingell (D-Mich.), whose lawmaker father co-authored the bill. "It was called socialized medicine. . . . They called Roosevelt a traitor to his class."

Presidents Harry S. Truman, Lyndon B. Johnson, Richard Nixon and Jimmy Carter proposed changes with only mixed success. The American health care system, shaped by job-based medical insurance and the fee-for-service payment system, became politically sacred.

In recent years, however, the system has come under mounting stress. It has been battered by waste and inefficiency but even more by changes in population and pricing and by an outpouring of scientific progress that threatens to bankrupt us with blessings.

Rising health care costs affect virtually every aspect of life--forcing firms to lay off workers or curtail benefits, eroding workers' pay increases, threatening the position of U.S. industries in the global marketplace.

Meanwhile, the growing strain of caring for the poor has degraded the quality and unbalanced the budgets of public hospitals in cities all over the country.

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