HEALTH PLAN'S DEVILISH DETAIL'S By Elizabeth McCaughey The news from the White House wasn't adding up. An estimated 38 million uninsured Americans would be given health coverage, yet the only new tax would be on cigarettes. The nation would limit health care spending, but no one would sacrifice choice or quality. I felt uneasy about the missing pieces. So I called the office of Sen. Harris Wofford (D., Pa.) and asked for a copy of the Clinton health plan. I read it and reread it-all 239 pages plus charts-poting over the details, consulting doctors and health care experts, and shaking my head at how different the plan is from what we are hearing. Here are the facts that surprised me, and that will probably trouble most people. Page numbers refer to the latest draft of the plan-the blueprint made availible to congress two weeks ago. ~UNDER THE CLINTON PLAN, MOST AMERICANS WILL NOT BE ABLE TO HOLD ONTO THEIR PERSONAL PHYSICIAN OR BUT THE KIND OF INSURANCE THAT 77% OF AMERICANS NOW CHOOSE. Such fee-for-service insurance allows them to pick a doctor, go to a specialist when they feel they need one, get a second opinion if they have doubts, and select the hospital they think is best. The Clinton plan will make almost all Americans buy basic health coverage through the "regional alliance" where they live. Regional alliances are HUGE GOVERNMENT MONOPOLIES that will purchase basic health care for everyone in the area. Alliance officials will negociate benefit packages and prices with insurers and health maintenance organizations (HMOs)-groups of physicians and hospitals that provide total health care through cost-conscious methods to each consumer for a prepaid premium. Unless you now receive health care through Medicare, millitary or veterans benefits, or unless you or your spouse works for a large company, the law will require you to bay basic health coverage from the LIMITED CHOICES offered by your alliance. It will be ILLEGAL to buy it elsewhere. (Pages 13, 15, 81.) Under the plan, the federal government will set ceilings on how much each regional alliance can spend on payments to insurers and HMOs annually. The goal is to limit private health care spending. Alliances can reject any health insurance operation that would push spending through the ceiling. Fee-for-service insurance, which tends to be more costly than HMO coverage will be the first to go. (Pages 42, 61.) In addition, an alliance cannot offer any plan that costs 20% more than the average price of all plans it offers. (Page 60.) Plans with added benefits (such as Pap smears every year instead of every third year) and many fee-for-service plans will be excluded by the 20% rule. A primary goal of the Clinton plan is to eliminate a two-tier health care system, where people who can pay more for medical care will receive more. The plan mandates "care based only on differences of need." (Page 11.) Annual ceilings and the 20% rule will make it VIRTUALLY IMPOSSIBLE for some alliances to offer choose-your-own doctor health insurance. Americans have been told that they will always have the option to buy fee-for-service insurance. But the plan says that, with a waiver from the National Health Board, alliances can EXCLUDE ALL fee-for-service plans, effectively FORCING millions of citizens to join an HMO. (Page 62.) Where a fee-for-service plan is offered, an alliance can impose a costly surcharge that will discourage consumers from choosing it. (Page 98.) Another rule, "community rating," requires insurers to offer the same basic package to everyone in the region for the same price. (Page 224.) Smokers and nonsmokers, drug abusers and nonusers pay the same. Community rating means that the sick are not thrown overboard, but it also makes those who adopt healthy behavior subsidize those who do not, and it pushes fee-for-service insurance out of reach of many Americans who now can affoard it. ~IT WILL BE HARD TO BUY ADDITIONAL INSURANCE. The basic benefit package is skimpy in some areas. But because of the community rating rule, insurers must offer supplemental policies to every person in a region at the same price (Page 81.) High risk individuals will line up, but insurers will not. Cara Walinsky of the Health Care Advisory Board and Government Committee, explains that the plan "will make it as difficult as possible for you to buy more insurance" than the standard package. ~SEEING A SPECIALIST AND PAYING FOR IT OUT-OF-POCKET WILL BE ALMOST IMPOSSIBLE. Few doctors will be practicing outside HMOs. The Clinton proposal is designed to drive doctors out of private practice. The plan has "very strong incentives built in that work against fee-for-service, not only on the consumer side, but also on the provider side," explains Ms. Walinsky. Even Drs. David Himmelstein and Steffie Woolhandler, leading proponents of a Canadian style single-payer system, warn that the plan will "obliterate private practice." ~PRICE CONTROLS WILL MAKE PRIVATE PRACTICE UNFEASIBLE. Americans have been told that there are no price controls. But the plan empowers alliances to set fees for doctors seeing patients on a fee-for-service basis. The plan states: "A provider may not charge or collect from a patient a fee in excess of the fee schedule adopted by an alliance." (Page 62.) ~AMERICANS HAVE BEEN TOLD THAT THE QUALITY OF HEALTH CARE WILL NOT DECLINE. MANY EXPERTS BELIEVE IT WILL. In HMOs, gatekeepers, or primary care physicians tightly limit patient use of specialists. Physician- subscriber ratios ratios at HMOs average 1 to 800, half the ratio of physicians to the nation's population. Under the plan, pressure on gatekeepers to curb access to specialists will increase. Ms. Walinsky predicts that above a threshold level of "reasonable quality," alliances will choose HMO's based on lowest cost, not highest quality, in order to meet federal spending limits. A parent lying awake, worried about a child's illness and whether the gatekeeper will OK a specialist, might think about bribes or even going outside the system. The Clinton plan anticipates the problem, with new criminal penalties for "payment of bribes or gratuities to influence the delivery of health service." (Page 9.) Doctors, meanwhile, joke about "offshore" practices, hospital ships outside the three mile limit, and other ways for families to escape controls and buy the health care they want. ~THE PLAN ALSO TAKES AWAY FROM HMO USERS THE LEGAL PROTECTION MANY STATE LAWMAKERS BELIEVE THEY SHOULD HAVE. Some states have passed "any willing provider" laws to prevent HMOs from arbitrarily excluding hospitals, pharmacies, or physicians from their networks. HMOs have protested that these laws hobble cost containment. The Clinton administration apparently agrees. The plan pre-empts STATE LAWS PROTECTING CONSUMER CHOICE. (Page 76) ~THE PLAN'S BIGGEST SURPRISE IS WHO BEARS THE COST OF UNIVERSAL HEALTH COVERAGE. The plan requires states to create health alliance regions -similar to election districs. How those alliance lines are drawn will determin which areas of the state are hit with the highest health care premiums, because they are shouldering the costs of health coverage for the inner city poor. THE SYSTEM PROMISES TO PIT BLACK AGAINST WHITE, POOR AGAINST RICH, CITY AGAINST SUBURB. The average treatment cost of a baby born addicted to drugs is $63,000. Because of community rating, anyone who lives in an urban alliance is going to pay high premiums, regardless of his health or behavior. Part of the premium covers his own care; part is a hidden tax to provide universal health coverage within the alliance. Some alliances will bear especially heavy social burdens, others will not. Everyone will figure out that you get more health care for your dollar or pay lower premiums in an alliance without inner city problems. The plan will be an INCENTIVE FOR EMPLOYERS TO ABANDON CITIES AND RELOCATE. Considering the number of court battles when states draw election districts, lawsuits over "medical gerrymandering" are inevitable. The plan sets out rules that will be dissected in courtrooms across the nation: States may not "concentrate racial or ethnic minority groups, socio- economic groups, or Medicaid benificiaries," and mayt not "subdivide a primary metropolitan statistical area." An alliance drawn to include a city and its surrounding suburbs will be considered in compliance. (Page 50) Home prices and litigation fees will rise and fall depending on which suburbs are sucked into a metropolitan alliance and which escape. Suppose a state fails to establish it's regional alliances on time, ot to meet all federal requirements? The plan empowers the secretary of the Treasury to "impose a payroll tax on all employers in the state. The payroll tax shall be sufficient to allow the federal government to provide health coverage to all individuals...and to reimburse the federal government for the cost of monitoring and operating the state system." (Page 47.) The plan does not set any limit on this tax. THE CLINTON PLAN IS COERCIVE. It takes personal health choices away from patients and families, and it also imposes a system of financing health care based on regional alliances that will make racial tensions fester and produce mean-spirited political struggles and lawsuits to shirk the cost of medical care for the urban poor. Members of Congressshould read the 239-page draft, rather than relying on what they hear, and then turn their attention to alternative proproposals that aim to provide universal coverage while avoiding the devastating consequences of the Clinton health plan. THE WALL STREET JOURNAL Thursday, September 30, 1993 Section A Page 18