Health Package Dilemma: What Should It Cover?

Hospitalization and visits to the doctor’s office will be covered. So will prenatal care and childhood immunizations. “Nothing,” says President Clinton, “will be more important than preventive care.”

But what about chiropractic services? And prescription drugs? Or coverage for mental health and drug abuse? Organ transplants? Vision and dental care? Prostate examinations?

Will mammograms and Pap smears be covered? If so, starting at what age, and how often? What about elective abortions?

These are a few of the vexing questions confronting the Clinton Administration as it nudges the nation toward a revamped health care system in which every American will have medical insurance.

By promising to enshrine universal coverage as a basic right, Clinton and his health care reform task force, led by First Lady Hillary Rodham Clinton, now must figure out what medical services their basic package of benefits will contain--and what it will not.

“This is the first and most basic issue that has to be solved,” said Bill Custer, research director of the Employee Benefits Research Institute.

The task promises to set off a high-stakes struggle among medical specialties and other providers that could bog down the entire reform initiative.

“The first explosion will come when the package of basic health benefits is unveiled,” predicted John J. Polk, president of the Council of Smaller Business Enterprises in Cleveland.

“Then the special interest groups will have at it. The mental health people, the substance abuse people, the AIDS people, the child health people, the naturalists, will all converge on Washington to assure they are represented in the package,” he said.

“If you’re not in that basic package, your livelihood is going to be threatened,” added Custer.

Such angst is already simmering. “The paranoia of my constituency is working overtime these days,” conceded John Carson, chief lobbyist for the American Podiatric Medical Assn., which represents foot doctors.

In designing a core package of benefits, the Administration must not only strike a balance among high-powered, competing interest groups, but also guard against offering too much--or too little.

Too rich an array of benefits could bankrupt a system already teetering on the brink of collapse. Too skimpy a package invites a Faustian bargain: If people lack certain medical coverages, they are likely to delay seeking care until their illnesses require far more expensive treatments.

“If we are going to expand coverage so that everybody is covered, and have cost control, that means very simply that not everything that everybody wants is going to be covered all the time,” warned Sen. John C. Danforth (R-Mo.).

The contents of a basic benefits package will have an impact far beyond the estimated 37 million uninsured Americans who would be covered by such a plan.

That’s because, as a way to help finance universal coverage, the Administration may levy a first-ever tax on the health benefits that workers receive from employers. And even though such a tax might apply only to the benefits above and beyond the core package, a broad coalition has formed to fight any effort to tax benefits at all.

Meanwhile, lobbying by various interest groups and individuals to have their pet services and causes included in the list of benefits is intensifying.

When Mrs. Clinton visited Capitol Hill two weeks ago in her first public appearance as head of the White House Task Force on National Health Care Reform, Senate Majority Leader George J. Mitchell (D-Me.) brought up his own pet topic.

In a meeting with the First Lady and her two top health policy advisers, Ira Magaziner and Judy Feder, Mitchell suggested that any basic insurance package must avoid funding the estimated one-third of all medical services and treatments that, studies show, are either ineffective or inappropriate.

Such research, pioneered by Dartmouth College’s John Wennberg, have shown, for instance, that people in some regions of the country receive as much as 70% more medical treatment than those who live elsewhere for the same conditions, with no difference in outcome. The disparities appear to reflect different practice patterns of doctors based on their training and community standards.

If a core benefits package eliminates this vast array of unnecessary services and treatments, Dr. Wennberg says, the savings can easily be “reallocated” to provide care to the uninsured.

At the end of last week, another leading advocate of “outcomes research,” David Eddy, a Jackson Hole, Wyo.-based physician and researcher, signed up with Clinton’s task force to help design the core benefits package--a task that has top priority, Administration sources say.

“Outcomes research may not be the answer to the ills of our health care system,” Eddy says. “But it sure is an important step. It’s a prerequisite.”

Others lobbying for their favorite services include Mary Elizabeth (Tipper) Gore, wife of the vice president, who holds a master’s degree in psychology and is a longtime champion of mental health services.

Appointed by Mrs. Clinton to the task force to focus on that issue, Mrs. Gore has been urging--in public and behind closed doors--that any core benefits package include mental health coverage.

The task force is “looking very hard” at community-based care, which can be “much more cheaply and more humanely” provided than institutional care, Mrs. Gore says. “We’re also looking at day treatment and respite care, and have that reimbursed.”

Mental health, says Custer, is likely to be among the thorniest questions confronting the task force. “It’s going to be very contentious. Mental health is one of the highest cost items that employers now cover.”

Even as such issues are being debated by the Clinton task force, various interest groups are making public appeals for their own causes.

“There’s a laundry list of things that need to be included,” says Jeff Levi, director of governmental affairs for the Washington-based AIDS Action Council.

“Clearly, for our purposes, the most important is going to be outpatient care and prescription drug coverage,” he says before ticking off a list: prenatal and well-baby care, mammograms, Pap smears, hospice care, substance abuse and mental health. “Ultimately, we have to do something about long-term care.

“These kinds of services are critical not just for people with AIDS but for anyone who might face a chronic disease--and millions of Americans do,” Levi says.

Groups that lobby on behalf of specific diseases are elated by President Clinton’s pronouncement Friday during a visit to a Virginia health clinic that preventive care has top ranking on his health care reform agenda.

“Our special view in cardiology is that the answer to the problem is in prevention and not late cure,” says cardiologist Rod Starke, senior vice president for scientific affairs for the American Heart Assn. An association committee is considering making recommendations on what cardiac-related services a basic benefits package should cover and how often, such as physical examinations, cholesterol measurements and blood pressure-taking.

Coverage for diet-counseling and smoking-cessation also can yield “enormous benefits” in helping avoid or delay costly surgery and other procedures, Starke adds.

Similarly, cancer prevention and early detection should occupy “a big part” of a core benefits package, says Alan Davis, vice president for public issues of the American Cancer Society.

Within the Clinton task force, a working group is debating what belongs in such a package. Sources say the task force will recommend, among other things, the creation of a national board that will continue to assess the package’s contents with an eye toward responding to changing needs.

Such a national panel also has been proposed in legislation introduced Feb. 4 by a bipartisan group of lawmakers in both chambers, led by Sen. Nancy Landon Kassebaum (R-Kan.).

She proposes that the creation of an independent commission to design the basic benefits package, a panel modeled after the Base Closing Commission that made recommendations on which military installations should be shut down in the post-Cold War era.

“Sen. Kassebaum has recognized that politicians are not very good at saying no,” says Danforth, a co-sponsor.

Without such a commission, he warns, “anytime anybody had a problem that was not covered by basic care, the pressure on Congress would be enormous to give the voters absolutely everything they want to have.”

Times staff writers Marlene Cimons and Robert A. Rosenblatt contributed to this story.