Rube Goldberg Won’t You Please Go Home : Health reform: The patched together bills will have terrible side effects, with younger people paying the highest price.

Among other things, the Democratic health-care plans contain a large--and unjustified--multibillion-dollar tax on younger workers. You wonder whether most members of Congress know this or even care. The whole health-care debate is now completely out of control. The desperate effort to craft something that can be advertised as “universal coverage” means that Congress literally no longer knows what it’s doing. Anything resembling the Democrats’ bills, if enacted, would produce tremendous unintended side effects.

Apparently, most Americans grasp this. In a Newsweek poll last week, respondents were asked whether Congress ought to “pass reform this year” or “start over next year.” By a 2-1 margin, they said start over. They sense that the versions of health reform crafted by House and Senate leaders are hodgepodges of conflicting provisions whose only purpose is to win passage. But what is clear to ordinary Americans is denied in Washington. In the capital, the fiction is that legislators know what they’re doing and are debating rational alternatives.

House Majority Leader Richard Gephardt’s plan, for instance, would create a Medicare Part C program for the unemployed, workers in small companies and many existing Medicaid recipients. The Congressional Budget Office estimates that the program might enroll 90 million people. But the projection could easily err by millions in either direction. More important, Medicare Part C emphasizes “fee for service” medicine (patients selecting individual doctors), while the rest of the bill emphasizes “managed competition” (reliance on health maintenance organizations and similar plans).

The bill would separate the under-65 population into two groups, mainly based on income and size of employer. Each group would be crudely steered toward a different type of medicine. In practice, this division may not be politically acceptable or economically workable. Gephardt doesn’t know; no one does.

Now, consider the tax on young workers. It arises from “community rating.” As people age, their health costs and insurance premiums rise. But community rating requires that everyone pay the same rate. This provision is included in the House bill and, in a modified version, in the Senate bill. The effect would be to raise insurance for younger workers (say, those below 45). If employers have to pay higher insurance, they will pay lower salaries. The invisible tax on young workers might total $25 billion annually.

Questions swirl around both Gephardt’s plan and Senate majority leader George Mitchell’s. It is hard even to describe Mitchell’s plan. He says it’s voluntary and lacks a “mandate.” Wrong. True, it doesn’t mandate companies to buy insurance for workers. But it does mandate a standard benefits package for firms--the vast majority--that offer insurance. Because the mandated benefits are above average, this would probably raise health spending. Companies below the new standard would increase benefits; those above would have trouble lowering them.

Next, Mitchell hopes to achieve 95% insurance coverage by offering subsidies for low-income workers to buy it. But there’s a “fail-safe” mechanism to limit subsidies if the budget costs exceed projected costs. However, if 95% coverage doesn’t occur by 2000, Congress could require employers to pay 50% of their workers’ insurance. But this would apply only to firms with more than 25 workers. Got it? No one knows whether this would reach 95% coverage.

These plans are confusing because the health debate evaded the basic tension between expanding health services (universal coverage, etc.) and controlling health spending. It’s hard to do both at the same time. The plans’ complexities--as with the original Clinton plan--aim to disguise this conflict. Republicans haven’t been especially constructive in this debate, because they haven’t faced up to it either. But they are now correct that a bad bill would be worse than none.

Chaos is now the most important reality about the health-care debate. Dozens of provisions in these bills would have huge unappreciated consequences. John Sheils of Lewin-VHI, a health consulting firm, says premiums for small businesses in the Mitchell bill could be 25% higher than for big companies. The budget office puts the gap lower. Who’s right? Do most members of Congress understand the gap? Probably not. Still, the pretense is that Congress is making conscious choices.

The pretense is sustained because in Washington politics is sport. All attention fixes on who wins and loses--and the deals that enliven the game. Rhetorical blasts are taken for reality; political reporters know little of how legislation would work and care less. This often leads to bad laws, and in health care, the potential for blunders is huge because Congress is tinkering with one-seventh of the economy and most aspects of medicine.

In May, Robert Reischauer, head of the budget office, warned that trying to find a compromise by combining provisions from different bills might make the health system worse. He compared it to building an auto engine with incompatible parts: “You can’t say I want a piston from Ford, a fuel pump from Toyota . . . and expect the engine to run.” Well, that’s what’s happened. The contraption is part car, part tractor and part rollerblades. Most Americans seem to understand this. Will Congress?