Central to Health Reform: Who Are the Uninsured?

IT is high noon for the health-care reform debate on Capitol Hill.

Many Republican and Democratic lawmakers, aware that time is running out before they will be forced to compromise or face possible voter discontent, are using these last weeks to make their arguments loud and clear.

The debate has boiled down to a few major issues, one being how many people should be insured under a new health system.

President Clinton has said he would veto a bill that does not guarantee health benefits for all Americans. His plan would provide nearly universal coverage by 1998. And he argues that most employers should be required to pay 80 percent of their workers' insurance because it is the surest route to universal coverage.

``[Employer mandates are] an American solution to an American problem,'' first lady Hillary Rodham Clinton said during a recent ``town meeting'' in Baltimore, Md.

Many Republicans and conservative Democrats say universal coverage through an employer mandate is an expensive and unnecessary goal that they will not accept.

Clinton may compromise

In order to pass a bill by October, the president may be willing to compromise.

Last week, a senior health-care adviser to the president said privately that Mr. Clinton would consider phasing in coverage as late as 2004, as long as the plan provides comprehensive coverage.

Such a compromise is being discussed by conservative Democrats and moderate Republicans - many of whom Clinton will have to win over in order to pass a health reform plan.

About 38 million people, or 17 percent of the population, are uninsured, according to the Employee Benefit Research Group. About 59 percent of these say they do without insurance because it is too expensive. Most are workers who have slipped through the cracks of the existing employer-based system, according to a report by the Henry J. Kaiser Foundation.

About 52 percent of the uninsured are in families of incomes below $20,000; 29 percent in families of incomes between $20,000-$39,000; and 19 percent in those above $39,000.

Republicans and Democrats interpret these figures differently, which has led to their different approaches to health reform.

``I don't agree with those figures. It's not like there are 38 million uninsured people driving around in a van together,'' said Rep. Fred Grandy (R) of Iowa.

Congressman Grandy argues that many people are uninsured for short periods of time, a problem he says should be solved through market competition and insurance reforms, not an employer mandate.

His ideas, detailed in a bill he drafted with Rep. Jim Cooper (D) of Tennessee, along with a bill offered by Sen. John Chafee (R) of Rhode Island, seem to be catching on among some conservative Democrats and moderate Republicans.

But Rep. Jim McDermott (D) of Washington says: ``If you have no health insurance, it does not matter if it is for one month or six months. [Republicans are] trying to say there is no problem.'' Without everyone under the tent of comprehensive health care, costs will continue to climb, he said, a viewpoint disputed by Republicans.

The Cooper-Grandy approach is under discussion by the Senate Finance Committee, which has been struggling behind closed doors to reach a compromise before voting on a bill.

Instead of enacting swift, comprehensive reforms, the bill would phase in universal coverage over a longer period of time than the president's 1998 deadline.

``We must rely on market forces to create a system in which informed, cost-conscious buyers switch to the most efficient system,'' says Rep. Michael Andrews (D) of Texas, a supporter of the Cooper-Grandy bill.

Unlike the president's bill, the Cooper-Grandy bill would not require employers to provide insurance for their workers. If by a certain date this softer approach does not work, employers would be required to provide insurance or Congress could be asked to revisit the issue.

91 percent covered

This approach would insure just 91 percent of the population, according to an analysis of the Cooper-Grandy bill by the Congressional Budget Office - not enough to satisfy a number of crucial Democratic senators.

After hearing reports of the possible compromise, four Democratic senators, led by Paul Wellstone of Minnesota, warned the president against caving in.

``Troubling signals have appeared from the press and some members indicating that universal coverage is not a realistic goal.... [We] will have difficulty sacrificing further,'' they said in a letter to Clinton.

Senator Wellstone and other senators held a meeting with the press. ``I resent the concept that we in Congress could ever think of passing something half-way,'' said Sen. Jay Rockefeller (D) of West Virginia.

``Only with universal coverage can we eliminate the practice of making patients with insurance pay the medical costs of those without it,'' Sen. Thomas Daschle (D) of South Dakota said. Incremental reforms would leave 24 million without coverage, he added.

Even with these developments, Sen. Edward Kennedy (D) of Massachusetts is optimistic about passage of comprehensive reforms. ``I watched 19 senators change their votes on Medicare in the six-week period before that program passed,'' he said.