Coming: basic change in federal health care role?

Washington is taking a new, more pragmatic approach toward paying for the health care of American citizens. Stunned by rocketing medical costs, politicians during the late 1970s and early '80s simply sat and wrung their hands, unable to agree on how to control government health spending. But that stalemate appears to have broken.

Recently passed changes in medicare and medicaid mean that ''for the first time, in a major way, Congress has admitted we can't have everything'' by way of health programs, says Louise Russell, senior fellow for health care at the Brookings Institution.

''This represents a fundamental change from the philosophy that has driven the system for a long time,'' she insists, ''and the beginning of a search for a new balance between the costs and benefits'' of increased government spending on health.

During the heady days of the Great Society, when medicare and medicaid were established, Congress solidly backed expansion of the federal role in providing health care to United States citizens.

Medical costs were increasing rapidly even then, but Congress paid little attention to the problem, secure in the belief that government health programs were ''a prudent and popular social investment,'' notes Harvard sociologist Paul Starr in his new book, ''The Social Transformation of American Medicine.''

By the late '70s, costs were going up so fast that Washington was compelled to pay attention. Spending for medicare and medicaid doubled between 1974 and 1977. Health programs are now the fourth-largest item in the federal budget, after defense, social security, and interest on the national debt.

A political standoff developed over how to best contain medical costs, Mr. Starr writes. Congress halfheartedly tinkered with federal health programs, but put off major overhauls, such as President Carter's cost-containment legislation.

Now, ballooning federal deficits and the deterioration of medicare's finances have forced Congress to take action. A spending cap, passed two years ago, will force many states to keep 1984 medicaid expenditures 4.5 percent lower than '81 levels. Under ''prospective payment,'' a provision of the recently passed social security rescue bill, hospitals will be paid predetermined flat fees for treating medicare patients. Previously, hospitals were reimbursed for their expenses, with an extra sum of money tacked on for profit.

These moves were ''simply unprecedented,'' says Mrs. Russell of Brookings.

Experts say this struggle to find more practical ways of financing government health programs is also reflected in Congress's current debate over health care coverage for the unemployed.

Double-digit unemployment may result in up to 20 million US citizens losing employer-provided health care insurance this year. With the strong support of organized labor and some key Republicans, including Sen. Robert Dole of Kansas, chairman of the Senate Finance Committee, federal health insurance for the out-of-work is gaining momentum on Capitol Hill.

Proposals range from Mr. Dole's limited, $750 million-a-year bill to a $2.7 billion proposal put forth by Rep. Henry A. Waxman (D) of California, chairman of a health subcommittee. But Congress, made wary by the double-digit growth of the big federal health programs, is studying how to keep the cost of health insurance for the unemployed from getting out of hand.

When it comes to health programs, however, Capitol Hill isn't being as parsimonious as the administration would like. President Reagan's '84 budget proposes spending $90.6 billion next year on health. The Senate Budget Committee wants to spend $92.1 billion for the same programs, while the budget resolution passed by the House allots $96.0 billion.

By upping the administration's ante, congressional aides say, Congress has served notice that it won't go along with Reagan's proposal to shift more of medicare's costs onto beneficiaries.

But it's unlikely that the subject of ''cost-sharing'' has thus been settled for good. Medicare and its financing problems are a subject Washington will hear more about before the end of the decade. A recent Congressional Budget Office report estimates that even with the cost-containment measures passed over the last several years, the medicare trust fund will run out of money by 1987 or '88 .