Clinton's Health Plan : Health Plan: A User's Guide : Prospects of Reform Hit Home

TIMES STAFF WRITER

Ever since President Clinton mounted the mahogany and marble podium in the well of the House of Representatives to present his blueprint for health care reform to a joint session of Congress, the plan has been getting the test that really counts in a far less august setting--the kitchen table.

Americans of all ages and circumstances are sitting down to try to calculate whether they would be winners or losers under the complex scheme. The President has promised to slow the runaway cost of the total U.S. health care bill and deliver good care for everyone, including the 37 million who do not now have health insurance.

But the proposal represents a series of trade-offs between benefits and cost saving, freedom of choice and out-of-pocket expense. What might be true for the country as a whole may or may not be true for any particular individual.

At this point, computing how particular individuals and families will fare can be no more than tentative. Clinton himself has yet to fill in all the details of his plan, Congress will undoubtedly modify the plan before it becomes law and sweeping change always brings unintended consequences.

"Over the long run, we can all win," Clinton insisted Wednesday in his address to Congress. "Some will have to pay more in the short run. Nevertheless, the vast majority of the Americans watching this tonight will pay the same or less for health care coverage that will be the same or better than the coverage they have tonight."

For many millions of Americans, Clinton's plan would be a resounding plus from the beginning. Included in this category are those who have no insurance, those who are locked in dead-end jobs because shifting careers would mean losing health coverage and those whose plans cover only the bare essentials. Even the elderly, already insured through Medicare, would gain coverage for prescription drugs.

John Stark, a 29-year-old uninsured bachelor in Fullerton, would be able to purchase peace of mind of knowing that if he got sick, his medical bills would be paid. The cost to him: as little as $30 a month.

Likewise, John F. Gominsky, 40, a Santa Ana man with a long history of cancer, would be able to change jobs without fear of being wiped out by medical bills. And Sherri Smith, 24, a Los Angeles welfare recipient who has trouble finding doctors who will accept MediCal patients, would move into the health care mainstream with benefits similar to those of privately insured people.

Not everyone may be happier, however.

Americans who are perfectly satisfied with their health care, young people who do not want to pay for health insurance, small business owners working on narrow profit margins, hospital administrators whose institutions depend on government payments, independent agents who sell health insurance--these people could see themselves as losers.

They include Carla Magarity, a Reseda insurance agent whose co-workers are already making grim jokes about being forced to go to work at fast-food restaurants; Ivan Calderon, who fears he would have to close his small Mexican restaurant in Costa Mesa if he were required to contribute toward his eight employees' health insurance, and Dr. Marvin Kaplan, who expects both lower fees and less work.

How individual Americans size up their prospects may determine the fate of the plan. Clinton has been counting on an outpouring of public support to help him overcome entrenched opposition from Republicans and some Democrats in Congress as well as lobbyists for the insurance industry, small businesses and other hostile special interests.

Already, the opponents have captured public attention with a television ad funded by the insurance industry. A husband and wife who are discussing the President's plan at their kitchen table conclude it would deprive them of their freedom to choose their own doctor.

"They choose, we lose," the couple says.

Clinton clearly had this ad in mind when he condemned "scare tactics by those who are motivated by the self-interest they have in the waste the system now generates."

In fact, the President's plan would not require Americans to switch doctors, although it might cost them more money to continue seeing the same physician. It includes powerful incentives for Americans to switch from insurance that reimburses any doctor on a fee-for-services basis to HMOs and other so-called managed care plans, which limit but do not eliminate their choices.

For those such as Gominsky who are willing to pay a higher deductible, fee-for-services plans will continue to be available.

Because the average cost of health insurance would vary from state to state, it is impossible for anyone to estimate with certainty what their costs would be. The Administration says the national average would be $1,800 for single people and $4,200 for families.

In general, employers would be required to pay up to 80% of the average premium in their region; employees would pay the difference between the employer payment and the cost of the plan they chose. By selecting a low-cost plan, individuals could hold down their costs.

Beyond their insurance costs, consumers would have to pay something whenever they sought health care. Those in low-cost health maintenance organizations would be charged $10 for every visit to the doctor, with an annual limit of $3,000 a year per family in out-of-pocket medical costs. Those who chose traditional fee-for-service medical care would have to pay 20% of their bills, up to an annual limit of $3,000.

The premium payments, deductibles, co-payments and benefits for consumers under the Clinton plan are said by the President to be consistent with those now enjoyed by employees of most Fortune 500 companies.

Perhaps the most enticing element of the President's plan for many people is the standard benefits package. While some existing plans offer more benefits, the vast majority of health insurance packages are no better than the one outlined by Clinton.

Employers could offer more than the Administration plan guarantees, but not less.

The standard package promises to cover doctor appointments, hospital and emergency services, clinical preventive services, mental health and substance abuse counseling, family planning and pregnancy care, hospice and home health care, ambulance service, laboratory and diagnostic procedures, rehabilitation, prosthetics, vision and hearing tests and preventive dental care for children.

As for Medicare beneficiaries, whose out-of-pocket costs have been rising, they have been promised drug benefits and long-term care benefits for the first time.

So far as employers are concerned, there is no denying that the President's plan would shift some of the financial burden from large firms with good health plans onto smaller companies that now provide little or no coverage. That is why M. Angelina Guirindola, benefits manager for California Federal Bank, favors the proposal; she thinks it will cut costs for CalFed.

In part, this is because doctors and hospitals that treat uninsured patients or those covered by Medicare, which limits the amount doctors and others can charge, compensate by increasing what they charge insured patients--a practice known as "cost shifting."

Even part-time workers and employees covered by their spouses' insurance would no longer represent a freebie for some employers. The amount that employers paid for part-timers would depend on how many hours a week they work. For two-wage-earner families, both employers would have to contribute, but the family would not be required to contribute twice.

Physicians, hospital administrators and many other health care professionals view the Clinton plan with suspicion, fearing the impact of its cost-saving provisions on their economic interests and on quality. Nurses are the exception, however, because they are being promised the larger role in diagnosis and treatment that they have long sought without success from doctors.

The forces most hostile to the plan are small insurance companies and insurance agents, both of whom fear being driven out of business by it.

Even those who stand to benefit from the President's plan cannot expect reform to bring everything they want without depriving them of something they now enjoy. As they weigh the pros and cons of this plan, most Americans will find that it is not all white or all black, but varied shades of gray.

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