THE CLINTON HEALTH PLAN : Health Care and You

President Clinton Wednesday night officially proposed the biggest changes in the nation’s health care system since Medicare was created in 1965. His plan will be subject to intense review and debate in Congress, and no one can predict the final shape health reform will take. But here is a consumer’s guide to what the new system may be like in California if Clinton’s plan becomes law.

STEP ONE: PICKING A PLAN

All Americans will receive a standard package of services to be delivered by a local network of doctors and hospitals. Local networks can offer additional services beyond the basic package, but these will cost extra. You select a network once a year and must receive all your care from than plan. To keep your current doctor, you would select the plan to which he or she belongs. Doctors will be allowed to sign up under more than one plan,

The Basic Services Offered to Everyone Hospital services Doctors and other health professionals’ services Emergency services Prenatal care and well-child checkups Preventive care such as physicals and mammograms Mental health care and substance abuse care Family planning and pregnancy-related services Hospice care Home health care Outpatient prescription drugs Outpatient laboratory and diagnostic charges Medical equipment, prosthetic and orthotic devices Vision and hearing care Dental services for children Ambulance services

How You Get the Services

You select a plan once a year, with probably as many as 7 to 10 alternatives in an area such as Southern California. The approved plans in the state might include such providers as: Kaiser Permanente: a health maintenance organization with its own staff of salaried doctors and its own medical centers. Blue Cross: A managed care network, made up of doctors and hospitals providing services at a negotiated fee schedule. Aetna: A network of doctors and hospitals assembled by a large insurance company. Other competitors such as Prudential or Metropolitan Life also would be in the market. Fee-for-service: Resembles traditional medicine, in which you have a much broader choice of doctors and hospitals but pay more.

The Extras

Besides the core package, consumers could add extras to the individual plan they pick. But such add-ons would have to come out of the consumer’s pocket.

The basic package would not include: Private duty nursing Private rooms Cosmetic surgery Cosmetic orthodontia Hearing aids In-vitro fertilization Custodial care (Some plans might offer these, but the consumers would have to pay extra premiums.)

STEP TWO: GOING FOR TREATMENT

All Americans would receive a health security card to be presented at the doctor’s office or hospital. The card would be used with a simple one-page insurance form, replacing the current paperwork blizzard. The card could be used to receive services from any doctor or hospital within the network plan you have chosen for the year.

STEP THREE: PAYING UP

All workers and employers would be required to contribute toward health insurance premiums, with workers paying about 20% of the cost of an average plan and employers about 80%.

If you choose a more expensive plan, you would be responsible for the added cost. The federal government would subsidize poor families and the unemployed. Subsidies also would be provided for businesses with fewer than 50 low-wage employees.

The typical HMO plan would require a co-payment of $10 for an office visit and $5 for a prescription drug.

A fee-for-service plan, with a much broader choice of doctors, would call for an annual deductible of $200 for an individual and $400 for a family. There would be a 20% co-payment for office visits. Drugs would have a $250 yearly deductible.

Other Features Self-employed individuals would pay both the employer and worker’s premiums but would bet a full tax deduction. Workers can pay their share of the premiums by withholding from wages, withholding from sources of non-wage income or by writing a check directly to the local health alliance. Workers under 18 are included in their parents’ coverage. Students away at college are covered by the health alliance in the school region.

THE PLAN’S ADVANTAGES AND DISADVANTAGES

For five typical health care consumers Family Description: Family making $50,000 a year with good employer-provided insurance Gains: Assured coverage, even if job is lost Losses: Premium deductions may be greater than family now pays as its share of employer’s medical plan Family Description: Family making $20,000 without insurance Gains: Assured coverage Losses: Some payroll deductions, with partial subsidies likely Family Description: Welfare family currently relying on Medicaid Gains: Access to more doctors and broader coverage Losses: None Family Description: Single person without insurance now and who can’t get coverage because of current illness Gains: Assured coverage despite existing illness Losses: Some payroll deductions Family Description: Retiree relying on Medicare Gains: Additional benefits, including some coverage for prescriptions and in-home care Losses: New restrictions on payments to doctors and hospitals could limit access to care for Medicare beneficiaries

TRACING YOUR HEALTH CARE DOLLAR

1) All workers and employers would pay proportionately. This would replace all current health insurance premiums paid by businesses and individuals.

2) Money is funneled to local consumer health alliance.

3) The alliance distributes the money to organizations such as insurance companies or health maintenance organizations that operate networks of doctors and hospitals.

4) The networks pay member doctors and hospitals.

WHEN WOULD IT START?

If Clinton’s plan is passed by Congress, most of the elements would be phased in over several years, with full implementation expected by the end of 1997.