House Leaders Study Slower Health Reform

House Democratic leaders, in their first tacit concession that major components of the Clinton health plan are unlikely to pass, are considering a more gradual approach that would not impose immediate cost controls or require Americans to join government-organized purchasing cooperatives.

However, Majority Leader Richard A. Gephardt (D-Mo.) said Thursday that Democratic leaders do not believe that they can abandon another controversial element of the President’s proposal--a requirement that employers buy health insurance for their workers. Unless employers are involved, Clinton’s basic aim of assuring that all Americans have health coverage is in jeopardy, he said.

Gephardt’s comments were the most explicit by any Democratic leader to date about the need to revise central elements of President Clinton’s plan.

His remarks were also significant in their timing. The health care debate “has just been blather up until now. Now, you’re getting down to serious business,” he said.

With polls showing the public increasingly uneasy about the specifics of the Clinton plan, a growing chorus of its opponents are declaring it doomed. In his comments to a small group of reporters, the majority leader seemed to concede the point in hopes of moving the debate forward to other alternatives.

“Everybody’s been wanting to pronounce dead or alive the Clinton bill, and I don’t think that’s relevant,” Gephardt said. “The question is, is there a way to get a bill that reflects their goals through the Congress and on his desk, and I think there is.”

The House initially had been considered a far more hospitable environment for the President’s plan than the Senate. But House Democratic leaders are finding, to their dismay, far more opposition to various parts of the plan than they had expected.

At least one key House subcommittee has abandoned any effort to agree on a version of the proposal. The Energy and Commerce Committee announced Wednesday that it will take the unusual step of bypassing its health and environment subcommittee to attempt to write the bill at the full committee level. But the panel’s Democratic membership is heavily weighted toward the more conservative end of the party.

Gephardt said survival of the health plan in the House is riding on the Ways and Means Committee, whose health subcommittee is scheduled to begin work next week.

“If you can get out of the Ways and Means Committee, I think you may have a bill that can get 218 votes (a majority) in the House,” the majority leader said.

Two approaches now appear to be taking shape among Democrats on the Ways and Means health subcommittee.

Rep. Pete Stark (D-Oakland), the panel’s chairman, is putting together an alternative that would establish a new Medicare program to cover the uninsured, require employers and employees to pay for health insurance and impose cost controls on premiums.

Another faction of the subcommittee is trying to fashion a version with less regulation than the Clinton plan. “We’re striving to see if we can find that balance that six of us can vote for,” said Rep. Sander M. Levin (D-Mich.), who is among those striving for the latter plan.

Outside the committee, however, a growing number of Democrats and Republicans apparently favor the idea that the best approach is a minimal one--and one that does not assure guaranteed health coverage for all Americans. These lawmakers advocate combining such widely agreed upon reforms as making coverage portable from one job to another and preventing insurance companies from denying policies to people who have serious illnesses.

Thirty House members--15 from each party--introduced such a bare-bones approach Thursday.

“Let’s get started with the foundation. We can build the house later,” said Rep. Bill Zeliff (R-N.H.), a co-sponsor of the legislation.

But Gephardt argued that, until everyone has health insurance, the only thing that marginal reforms will produce is higher insurance premiums. That is because the costs of medical care for the uninsured would continue to be shifted onto people who have coverage.

Some argue that costs would rise even faster because insurance companies would be forced to offer coverage to sicker people, whose care is the most expensive, but would do so without receiving premiums from healthy people who choose to remain without coverage.

“The minimalist approach to me makes no sense,” Gephardt said. “It will denigrate the name of reform because most people’s premiums would go up with no benefit.”

Many objections to the Clinton bill have centered on its intent to force more than 70% of the population into purchasing cooperatives, known as alliances. Some contend that mandatory alliances would inject too much big government into the health care system, and others have suggested that the elaborate structure is too complicated to work.

“I think you can make alliances less mandatory; you can adjust the way they work and still achieve the goals,” Gephardt said.

He also said it may not be necessary to impose government controls on the growth of health insurance premium costs: “A lot of objective observers believe that, if you have real competition, everybody (covered), you will get real cost constraint.”

However, Gephardt said he did not see any means of achieving universal coverage without “some eventual way of requiring that all employers and employees be involved in health care.”

He suggested that there might be significant room for compromise from Clinton’s proposal, which requires most companies to pay 80% of their workers’ premium costs. Among the options he cited: phasing in the mandate over a longer period, lowering the employer share or exempting smaller firms while giving their workers government subsidies to pay for their own insurance.

Democrats also are keeping a wary eye on a group of Senate and House Republicans who left Thursday for a Maryland retreat at which they will attempt to find more consensus in their party, where a strong conservative faction is arguing against a bill far-reaching enough to cover everyone.

Sen. John H. Chafee (R-R.I.), author of a comprehensive health plan sharing many of the Clinton goals, will attempt to convince his more conservative colleagues that universal coverage is crucial to any reform effort.