
                      HEALTH PLAN'S DEVILISH DETAIL'S
                           By Elizabeth McCaughey

        The news from the White House wasn't adding up.  An estimated 38
million uninsured Americans would be given health coverage, yet the only
new tax would be on cigarettes.  The nation would limit health care spending,

but no one would sacrifice choice or quality.  I felt uneasy about the
missing pieces.
        So I called the office of Sen. Harris Wofford (D., Pa.) and asked for
a copy of the Clinton health plan.  I read it and reread it-all 239 pages
plus charts-poting over the details, consulting doctors and health care
experts, and shaking my head at how different the plan is from what we
are hearing.
        Here are the facts that surprised me, and that will probably trouble
most people.  Page numbers refer to the latest draft of the plan-the
blueprint made availible to congress two weeks ago.
        ~UNDER THE CLINTON PLAN, MOST AMERICANS WILL NOT BE ABLE TO HOLD ONTO
THEIR PERSONAL PHYSICIAN OR BUT THE KIND OF INSURANCE THAT 77% OF AMERICANS
NOW CHOOSE.  Such fee-for-service insurance allows them to pick a doctor,
go to a specialist when they feel they need one, get a second opinion if they
have doubts, and select the hospital they think is best.
        The Clinton plan will make almost all Americans buy basic health
coverage through the "regional alliance" where they live.  Regional alliances
are HUGE GOVERNMENT MONOPOLIES that will purchase basic health care for
everyone in the area.
        Alliance officials will negociate benefit packages and prices with
insurers and health maintenance organizations (HMOs)-groups of physicians
and hospitals that provide total health care through cost-conscious methods
to each consumer for a prepaid premium.  Unless you now receive health care
through Medicare, millitary or veterans benefits, or unless you or your
spouse works for a large company, the law will require you to bay basic
health coverage from the LIMITED CHOICES offered by your alliance.  It will
be ILLEGAL to buy it elsewhere.  (Pages 13, 15, 81.)
        Under the plan, the federal government will set ceilings on how much
each regional alliance can spend on payments to insurers and HMOs annually.
The goal is to limit private health care spending.  Alliances can reject any
health insurance operation that would push spending through the ceiling.
Fee-for-service insurance, which tends to be more costly than HMO coverage
will be the first to go. (Pages 42, 61.)
        In addition, an alliance cannot offer any plan that costs 20% more
than the average price of all plans it offers.  (Page 60.)  Plans with added
benefits (such as Pap smears every year instead of every third year) and many
fee-for-service plans will be excluded by the 20% rule.  A primary goal of
the Clinton plan is to eliminate a two-tier health care system, where people
who can pay more for medical care will receive more.  The plan mandates
"care based only on differences of need."  (Page 11.)
        Annual ceilings and the 20% rule will make it VIRTUALLY IMPOSSIBLE
for some alliances to offer choose-your-own doctor health insurance.
Americans have been told that they will always have the option to buy
fee-for-service insurance.  But the plan says that, with a waiver from the
National Health Board, alliances can EXCLUDE ALL fee-for-service plans,
effectively FORCING millions of citizens to join an HMO.  (Page 62.)
        Where a fee-for-service plan is offered, an alliance can impose a
costly surcharge that will discourage consumers from choosing it.  (Page 98.)
Another rule, "community rating," requires insurers to offer the same basic
package to everyone in the region for the same price.  (Page 224.)
Smokers and nonsmokers, drug abusers and nonusers pay the same.  Community
rating means that the sick are not thrown overboard, but it also makes those
who adopt healthy behavior subsidize those who do not, and it pushes
fee-for-service insurance out of reach of many Americans who now can
affoard it.
        ~IT WILL BE HARD TO BUY ADDITIONAL INSURANCE.  The basic benefit
package is skimpy in some areas.  But because of the community rating rule,
insurers must offer supplemental policies to every person in a region at the
same price (Page 81.)  High risk individuals will line up, but insurers will
not.  Cara Walinsky of the Health Care Advisory Board and Government
Committee, explains that the plan "will make it as difficult as possible for
you to buy more insurance" than the standard package.
        ~SEEING A SPECIALIST AND PAYING FOR IT OUT-OF-POCKET WILL BE ALMOST
IMPOSSIBLE.  Few doctors will be practicing outside HMOs.  The Clinton
proposal is designed to drive doctors out of private practice.  The plan has
"very strong incentives built in that work against fee-for-service, not only
on the consumer side, but also on the provider side," explains Ms. Walinsky.
Even Drs. David Himmelstein and Steffie Woolhandler, leading proponents of
a Canadian style single-payer system, warn that the plan will "obliterate
private practice."
        ~PRICE CONTROLS WILL MAKE PRIVATE PRACTICE UNFEASIBLE.  Americans
have been told that there are no price controls.  But the plan empowers
alliances to set fees for doctors seeing patients on a fee-for-service
basis.  The plan states: "A provider may not charge or collect from a patient
a fee in excess of the fee schedule adopted by an alliance."  (Page 62.)
        ~AMERICANS HAVE BEEN TOLD THAT THE QUALITY OF HEALTH CARE WILL NOT
DECLINE.  MANY EXPERTS BELIEVE IT WILL.  In HMOs, gatekeepers, or primary
care physicians tightly limit patient use of specialists.  Physician-
subscriber ratios ratios at HMOs average 1 to 800, half the ratio of
physicians to the nation's population.  Under the plan, pressure on
gatekeepers to curb access to specialists will increase.  Ms. Walinsky
predicts that above a threshold level of "reasonable quality," alliances will
choose HMO's based on lowest cost, not highest quality, in order to meet
federal spending limits.
        A parent lying awake, worried about a child's illness and whether the
gatekeeper will OK a specialist, might think about bribes or even going
outside the system.  The Clinton plan anticipates the problem, with new
criminal penalties for "payment of bribes or gratuities to influence the
delivery of health service." (Page 9.)  Doctors, meanwhile, joke about
"offshore" practices, hospital ships outside the three mile limit, and other
ways for families to escape controls and buy the health care they want.
        ~THE PLAN ALSO TAKES AWAY FROM HMO USERS THE LEGAL PROTECTION MANY
STATE LAWMAKERS BELIEVE THEY SHOULD HAVE.  Some states have passed "any
willing provider" laws to prevent HMOs from arbitrarily excluding hospitals,
pharmacies, or physicians from their networks.  HMOs have protested that
these laws hobble cost containment.  The Clinton administration apparently
agrees.  The plan pre-empts STATE LAWS PROTECTING CONSUMER CHOICE. (Page 76)
        ~THE PLAN'S BIGGEST SURPRISE IS WHO BEARS THE COST OF UNIVERSAL
HEALTH COVERAGE.  The plan requires states to create health alliance regions
-similar to election districs.  How those alliance lines are drawn will
determin which areas of the state are hit with the highest health care
premiums, because they are shouldering the costs of health coverage for the
inner city poor.  THE SYSTEM PROMISES TO PIT BLACK AGAINST WHITE, POOR
AGAINST RICH, CITY AGAINST SUBURB.
        The average treatment cost of a baby born addicted to drugs is
$63,000.  Because of community rating, anyone who lives in an urban alliance
is going to pay high premiums, regardless of his health or behavior.  Part of
the premium covers his own care; part is a hidden tax to provide universal
health coverage within the alliance.  Some alliances will bear especially
heavy social burdens, others will not.  Everyone will figure out that you
get more health care for your dollar or pay lower premiums in an alliance
without inner city problems.  The plan will be an INCENTIVE FOR EMPLOYERS
TO ABANDON CITIES AND RELOCATE.
        Considering the number of court battles when states draw election
districts, lawsuits over "medical gerrymandering" are inevitable.  The plan
sets out rules that will be dissected in courtrooms across the nation:
States may not "concentrate racial or ethnic minority groups, socio-
economic groups, or Medicaid benificiaries," and mayt not "subdivide a
primary metropolitan statistical area."  An alliance drawn to include a
city and its surrounding suburbs will be considered in compliance.  (Page 50)
Home prices and litigation fees will rise and fall depending on which suburbs
are sucked into a metropolitan alliance and which escape.
        Suppose a state fails to establish it's regional alliances on time,
ot to meet all federal requirements?  The plan empowers the secretary of the
Treasury to "impose a payroll tax on all employers in the state.  The
payroll tax shall be sufficient to allow the federal government to provide
health coverage to all individuals...and to reimburse the federal government
for the cost of monitoring and operating the state system." (Page 47.)
The plan does not set any limit on this tax.
        THE CLINTON PLAN IS COERCIVE.  It takes personal health choices
away from patients and families, and it also imposes a system of financing
health care based on regional alliances that will make racial tensions
fester and produce mean-spirited political struggles and lawsuits to shirk
the cost of medical care for the urban poor.
        Members of Congressshould read the 239-page draft, rather than
relying on what they hear, and then turn their attention to alternative
proproposals that aim to provide universal coverage while avoiding the
devastating consequences of the Clinton health plan.

THE WALL STREET JOURNAL
Thursday, September 30, 1993
Section A  Page 18

