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Advocates Worry Health Debate Will Lose Sight of Children

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The debate on health-care reform has focused on President Clinton's proposed "health security act,'' and lawmakers are expected to use that bill as the basis for their work.

Yet, many alternative pieces of health-care legislation--ranging from minor tinkering with the status quo to a plan that would essentially result in socialized medicine--have been introduced.

While no single alternative plan has stolen the spotlight from the Administration's bill, some competing proposals have attracted interest, and their content provides an indication of which issues are likely to be actively contested on Capitol Hill as Congress struggles to form a consensus on health care.

Because education and child-advocacy groups generally approach the issue from the standpoint of securing health benefits for children, they fear that this debate will ultimately water down the elements of the Clinton plan that they find attractive.

Most of all, education advocates hope Congress will seek to insure that every child comes to school healthy enough to learn.

"The single most important thing is that all kids are covered,'' said Bruce Hunter, the senior associate executive director of the American Association of School Administrators.

But some of the alternative plans would not provide the universal health coverage that the President has said must be the foundation of a reform bill if he is to sign it.

Chief among them is the measure proposed by Rep. Jim Cooper, D-Tenn., which has gotten some serious scrutiny in the national media over the past few weeks.

The Cooper plan would achieve cost controls by encouraging competition among health plans. Companies would be required to offer--but not to pay for--their employees' insurance, and subsidies would be available for the low-income uninsured.

No Guarantees

Other conservative approaches would also not guarantee universal coverage.

For example, a plan to be introduced by Sen. Phil Gramm, R-Tex., would allow employers to set up medical savings accounts for employees, who could then use that tax-free money for costs not paid for by insurance.

A plan sponsored by Sen. Don Nickles, R-Okla., would essentially require all Americans to purchase insurance--an approach critics say will not insure that they will do so. Mr. Nickles argues that, if individuals are made to budget their own health-care dollars, price-conscious consumers will force costs down.

Bret Bernhardt, the senator's legislative director, acknowledged that mandated insurance is an unpopular idea, but said the real intent is to serve as a moderating force in the health-reform debate.

The message, he said, is: "Let's keep this thing in perspective.''

The plan proposed by a group of Republican senators led by Sen. John H. Chafee, R-R.I., is similar to the Clinton plan in that it would set up a new system under which health care would be purchased through large collectives.

But instead of requiring employers to foot much of the bill, as the Clinton plan would, Mr. Chafee would require individuals to purchase at least a standard, catastrophic-benefit plan or risk substantial penalties should they need care. Employers would only be required to offer access to insurance.

Joel Packer, a senior professional associate at the National Education Association, pointed out that Mr. Chafee's plan to provide health-care subsidies to low-income people depends on achieving savings in other areas.

"If the cost savings don't materialize,'' he said, "there won't be any vouchers.''

Socialized Medicine?

Many child advocates would prefer a Canadian-style, "single payer'' plan, such as the one introduced by Sen. Paul Wellstone, D-Minn., and Rep. Jim McDermott, D-Wash.

The Wellstone bill would provide universal coverage by making the federal government the sole provider of health care, taking in tax monies and paying health-care providers.

Supporters argue that this would simplify administration, guarantee universal coverage, and provide a wide scope of benefits.

The single-payer bill offers what many say are the best mental-health benefits, for example.

And, like the Clinton plan, a single-payer system would presumably take some financial pressure off schools by paying for the medical needs of special-education students, something advocates fear the more conservative plans would not guarantee coverage for.

Indeed, the Clinton and Wellstone plans are the only ones that specify what would be included in the standard coverage they would guarantee, reassuring advocates who want to insure that benefits such as immunizations are covered.

Those plans are also the only ones that specifically include school-based clinics as health-care providers. The Clinton plan would also directly help launch such clinics and includes a series of health-education programs as well.

Support for the single-payer idea has influenced the Administration to include provisions in its legislation allowing states to experiment with single-payer systems, Elliot Weiner, an aide to Mr. Wellstone, said, adding that the senator hopes to insure high levels of mental-health and substance-abuse treatment in whatever package is enacted.

However, even supporters say that Congress is unlikely to adopt a government-run health-care system, and, largely for that reason, education and children's groups are virtually unanimous in supporting the Clinton plan.

"The plan that's going to happen is the Clinton plan,'' said Myrna Mandlawitz, a government-affairs representative for the National Association of State Directors of Special Education.

"We're backing the Administration's plan because the other plans don't all offer universal coverage, and don't specify children with disabilities,'' Ms. Mandlawitz said.

The Employer Mandate

But education groups' enthusiasm is not unqualified. School districts and states are employers, and do not want to see their health-care costs rise, as they might under Mr. Clinton's proposal to require employers to pay 80 percent of employees' premiums.

Laurie Wesley, the chief legislative counsel for the National School Boards Association, said that the employer mandate would cause a "substantial increase'' in districts' health-care costs, a point disputed by some other analysts.

The N.S.B.A. supports universal coverage, she said, but "the way in which universal coverage is being attempted'' poses potential problems for schools.

Meanwhile, groups representing teachers and other school workers want to insure that their health benefits--which are often better than what the average American receives--are not curtailed.

Those criticisms of the Clinton plan are echoed more loudly by business groups and organized labor nationally. Over all, education groups and child advocates are more concerned that Congress will do less than Mr. Clinton proposed.

Some observers say that recent developments--such as criticism of Mr. Clinton's plan by Sen. Daniel Patrick Moynihan, D-N.Y., and widely publicized assertions by Republicans that there is no health-care crisis--have cast some doubt on the future of major reform.

"The momentum has unfortunately shifted against the Clinton bill,'' Mr. Packer said. "We're hoping that it shifts back.''

Observers are awaiting the scheduled release this week of an analysis by the Congressional Budget Office of the financial feasibility of the Clinton proposal. The non-partisan C.B.O.'s report is expected to be influential.

Some observers say lawmakers may not be able to achieve consensus on anything other than a minor adjustment of the current health-insurance system, such as the proposal backed by the House Republican leadership.

But most analysts predict that Congress will pass some sort of health-care-reform bill this year.

"If Congress doesn't do something,'' Mr. Packer of the N.E.A. said, "a lot of members will have to explain to their constituents why they didn't do anything.''

Major Health-Care Proposals At a Glance

Health Security Act
S 1757, HR 3600
Sponsors: Sen. George J. Mitchell, D-Maine; Rep. Richard A. Gephardt, D-Mo.

The Administration's plan promises to provide every American with health-care coverage by 1998. It would require employers to pay 80 percent of their employees' insurance premiums. Individuals would choose a plan from those offered by regional health-care alliances; government subsidies would help low-income people pay for their coverage. The public-health section includes grants for establishing school-based clinics and health-education initiatives, including specific language on the scope of health education. The legislation also lays out a basic package of benefits, including some coverage for special-education students' medical services, and some mental-health benefits, with increased benefits to be phased in at later dates.

American Health Security Act
S 491, HR 1200
Sponsors: Sen. Paul Wellstone, D-Minn.,; Rep. Jim McDermott, D-Wash.

The "single payer" plan would offer universal coverage by 1995. It would be administered by states and funded by the federal government through a new payroll tax. The plan offers unrestricted choice of health-care provider. Children's benefits include basic immunizations, routine dental care, eyeglasses, hearing aids, and long-term, acute, and chronic-care services. The plan would also cover occupational therapy, physical therapy, and other medically related special-education services. A national health board would oversee the program and set preventive-care schedules. The plan would also provide extensive mental-health benefits. School-based health clinics are specifically named as potential qualified health-care providers. Under the plan, those now on Medicaid would receive the same benefits as all other Americans.

Managed Competition Act
S 1579, HR 3222
Sponsors: Sen. John B. Breaux, D-La.; Rep. Jim Cooper, D-Tenn.

The act would make conventional health insurance available to all Americans. It would require businesses with fewer than 100 employees to provide access to health coverage through alliances; the low-income uninsured would be eligible for subsidies. Those who do not enroll in health maintenance orgainzations would be subject to tax penalties.

Health Equity and Access Reform Today Act
S 1770
Sponsor: Sen. John H. Chafee, R-R.I.

The bill would require all employers to offer, but not to pay for, insurance for their employees. The plan would offer universal coverage through an individual mandate: All individuals will be required to obtain coverage by 2005. The bill would offer vouchers to low-income people not on Medicaid, phased in to cover those at 240 percent of the poverty line by 2005. A national health board would set up a standard benefits package. Small businesses would have access to purchasing groups to insure that they had the same range of plans to choose from as bigger busineses.

Affordable Health Care Now Act
HR 3080
Sponsor: Rep. Robert H. Michel, R-Ill.

The House Republicans' bill would require all employers to offer, but not to pay for, insurance for their employees. Insurers would not be allowed to exclude coverage of pre-existing conditions. Employers could offer medical savings accounts with tax breaks to encourage individuals to control their own health-care spending.

Consumer Choice Health Security Act
S 1743, HR 3698
Sponsors: Sen Don Nickles, R-Okla.; Rep. Cliff Stearns, R-Fla.

The act would require individuals and families not on Medicaid or Medicare to purchase at least a minimum of "acute care" health coverage. The bill would authorize employers to withhold premiums from employee paychecks to insure that premium payments are made. It would encourage competition between insurance companies in order to keep down costs. Insurers would not be allowed to exclude coverage of pre-existing conditions, nor avoid covering individuals with a history of illness. Insurers would be able to offer incentive discounts for "healthy behavior." Individuals and families could deposit money into medical savings accounts. They would receive tax credits for the deposits, health-insurance premiums, and any out-of-pocket medical expenses.

Comprehensive Family Health Access and Savings Act
S 1807
Sponsor: Sen. Phil Gramm, R-Tex.

Without much deviation from the current health-care system, the plan would "encourage responsible behavior by the financially capable" by creating incentives for individuals and families over 200 percent of the poverty line to purchase at least catastrophic insurance. It would set up medical savings accounts into which employers would pay any difference between the catastrophic insurance premiums and what they would have paid for more comprehensive insurance. Any money from the accounts used for medical expenses would be tax-free. The plan also would allow insurers to determine charges depending on lifestyle. The plan would leave the Medicaid system intact but cut its annual rate of increase.

Sources: Congressional offices and staff.

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