GOVERNMENT & MEDICINE

Clinton aims at health reform legacy

President Clinton's plan to provide coverage to some of the uninsured is far from a done deal. But it is a start, many observers say.

By Susan J. Landers, AMNews staff. Feb. 7, 2000. - Additional information.

Washington -- President Clinton's second major attempt at expanding health coverage to the uninsured is modest compared with his quest seven years ago to revamp the health care system. But the new plan's future is still far from certain as some policymakers praise it for its ambition and others deride it as falling short.

Although the plan's fate is unclear in this year of presidential politics, "it does put something on the table in case Congress does want to act," said Robert Blendon, PhD, a professor at the Harvard University School of Public Health. The plan would cover 5 million of the 44 million uninsured Americans at an estimated cost of $110 billion over 10 years.

Clinton's attempt to build a health care legacy in his last year in office also has played a role in his decision to craft a plan that contains a "series of incremental pieces -- which are not insignificant -- with the idea that this is probably as far as this Congress will go," Dr. Blendon said.

But Paul B. Ginsburg, PhD, the president of the Center for Studying Health System Change, an independent research organization, sees President Clinton's plan as more sweeping in scope and describes it as "comprehensive incrementalism."

"It seems to have an increment for every definable population that has trouble getting insurance coverage," he said.

Health care has emerged this year as an issue of concern to voters, according to a new survey by the Kaiser Family Foundation and Harvard. But although health care issues rank higher in voters' eyes this year than in 1998, Dr. Blendon noted, they don't reach the high levels of 1992, when Clinton was first elected on a health care agenda -- one that failed spectacularly to reach fruition.

"Health care issues will not decide the 2000 elections, but they could be a critical factor in races that are close," said Drew E. Altman, PhD, president of the Kaiser Family Foundation.

Sen. William V. Roth Jr. (R, Del.), chairman of the influential Senate Finance Committee, did not greet Clinton's proposal with great enthusiasm. He said that he would examine it and that he hoped for a bipartisan solution to the problem of the uninsured. But Roth also made note of a presidential veto last year of "legislation that addressed the needs of America's uninsured."

Multi-pronged approach

The president's plan will be included in his final budget, scheduled for Capitol Hill delivery in late January, and was to be featured in his last State of the Union message. It contains four separate initiatives. The plan would:

Create a new "FamilyCare Program" to provide coverage for the parents of children eligible for Medicaid or for the State Children's Health Insurance Program. The new program would cover about 4 million of those now uninsured and cost $76 billion over 10 years.

More than 80% of parents of uninsured children with incomes below 200% of poverty (about $33,000 for a family of four) are themselves uninsured, said the White House.

FamilyCare, similar to a plan being promoted by Vice President Al Gore in his pursuit of the Democratic presidential nomination, would employ basically the same state systems, rules and overseeing agencies as are used to administer Medicaid and SCHIP.

The administration also is counting on the offer of parental coverage to help expand the enrollment of children in Medicaid and SCHIP. An estimated 11 million children are now uninsured, says a Kaiser Foundation study released last month.

"When you have a family coverage benefit," said a senior Clinton administration official, "you have greater incentives to cover both family and children, and we think it will have a double benefit."

Eliminate some barriers to enrollment in SCHIP and Medicaid. This portion of the president's plan is expected to provide coverage to 400,000 currently uninsured children at a cost of $5.5 billion over 10 years. Many states are not now allowed to enroll children at school, child care centers or homeless shelters. Clinton's plan would allow school lunch programs to share information with Medicaid, broaden the array of enrollment sites and require states to make enrollment easier for both SCHIP and Medicaid.

Establish a Medicare buy-in option for 55- to 65-year-olds and provide tax credits to help pay for premiums, including those for continuing employer-sponsored coverage under the Consolidated Omnibus Budget Reconciliation Act, or COBRA.

The proposal also extends Medicaid and SCHIP to 19- and 20-year-olds, extends Medicaid eligibility indefinitely to those leaving welfare for work and provides SCHIP coverage to the children of legal immigrants.

The provisions would cost an estimated $28.7 billion over 10 years and cover about 600,000 people.

Increase funding to programs run by physicians, hospitals or clinics that provide health care directly to the uninsured and to community health centers that serve low-income and uninsured people. The initiative would cost about $1 billion over 10 years.

Opinions vary

Clinton's plan received mixed reviews from interest groups. AMA President Thomas R. Reardon, MD, said the Association would study it.

"You have to look at the details, see how it will be financed and whom it will cover," he said.

The need to provide coverage for the uninsured emerged as a top priority in a meeting last fall of a diverse gathering of more than 50 interest groups and led in part by the AMA.

In addition, the AMA's National House Call campaign has hit the election trail to help focus attention on such health care issues as the passage of strong managed care legislation, Medicare reform and universal health insurance coverage.

American Hospital Assn. President Dick Davidson commented that Clinton took the right approach in focusing on children, working families and early retirees.

"We assume the administration will look to the nation's burgeoning surplus to finance these important programs, rather than propose additional reductions to already strapped hospitals," he added.

The Health Insurance Assn. of America praised the president's plan and stated that it is, in some respects, identical to "InsureUSA," a plan crafted by HIAA.

A group of small, independent businesses, however, expressed disappointment with Clinton's plan. Dan Danner, senior vice president of the National Federation of Independent Business, said owners of small businesses instead would favor the expansion of medical savings accounts and 100% deductibility of health care costs for the self-employed and those who pay for their own insurance.

Quentin Young, MD, a long-time booster of universal health care, called the president's plan "thin gruel." Clinton's legacy year "would be the moment for a lame duck to show some leadership, and this incremental nonsense isn't doing it," he said.

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