Slip of the Tongue or Backtracking? Clinton Clarifies `Universal' Care

WHEN President Clinton expounded in public last week on how his idea of ``universal'' health insurance coverage would never actually cover everybody, the news media led a storm surge of interpretation.

The president, concluded many members of Congress either with chagrin or delight, was backing off on his condition that reform must offer every American private insurance with comprehensive benefits.

The White House spent the next couple of days trying to undo this impression. Yet most experts, including those in the White House, would say that Mr. Clinton's remarks were technically accurate - and not a shift in policy at all.

The possibility that the president could be starting to squirm away from universal coverage was an especially sensitive point in the House of Representatives.

In a negative lesson fresh in the minds of many from a year ago, the House voted for a Clinton-requested tax on energy, only to have Clinton back away from the tax when dealing with the Senate.

House members are not willing to make any tough votes this election season just to have them undermined in the Senate.

This week, House Majority Leader Richard Gephardt of Missouri is suggesting that the House may vote on a health-care reform bill that puts off all changes in the system for several years. Some analysts read this to mean that he wants the Senate to go first.

The goal of universal coverage is the point that much of the health-care debate has been pinwheeling around.

It is highly popular with the public, and it is the single element that must be included in a bill to avoid a Clinton veto. But universal coverage is also expensive, and any method of actually achieving it is consistently opposed by nearly half the voting-age population.

Clinton told the nation's governors last week that even a nominally universal program such as Social Security - for those over 65 - only reaches about 98 percent of the age group it covers.

So health reform should reach 96, 97, or 98 percent of Americans, he said. Later, to reporters, he set a mark of 95 percent or higher.

His estimates are supported by independent researchers. Social Security, in practice, excludes about 2 percent of the elderly population because it is based on work history. So a few immigrants who arrived in the US past retirement, some women who never worked or married, and a few idle rich who never collected a paycheck are left out of the system, says Marilyn Moon, an expert on entitlement programs at the Urban Institute in Washington.

Medicare, another program intended to include everyone over 65, leaves out the same small slice of the population as Social Security.

If health-care reform mandates coverage for everyone by a certain date, it is likely in practice to still only cover 95 or 96 percent of the population, says Henry Aaron, a senior fellow at the Brookings Institution.

``This numbers game has been a bit foolish,'' he says. It turns on the confusion between the legal requirement or entitlement to coverage and actual coverage in practice.

Legally covering 100 percent of the population will still leave out some of the homeless, those who are remote from civilization, and the feckless who choose to avoid the system, he says.

Hawaii, for example, is the only state that has an operating mandate requiring employers to offer insurance to their employees, with a state-supported system to cover everyone else. But Hawaii still has 6 or 7 percent uninsured - in part perhaps because some workers are employed off-the-books in the underground economy.

So Clinton can speak of 95 percent coverage or higher without backing away from his goal of 100 percent entitlement to health insurance, even though he still may have been sending a signal that he was softening his line in the sand.

Without mandates - either employer mandates that they pay for most of their employees' insurance premiums or a mandate requiring individuals to be insured with a subsidy for those who need it - ``we haven't a prayer of a significant increase in coverage,'' Dr. Aaron says.

Of the five bills before either the House or Senate now, they all mandate universal coverage except for the one forged in the Senate Finance Committee. This bill is the only one with significant bipartisan support and is considered the most likely to pass the Senate.

The Finance bill would ask Congress to consider further action if 95 percent coverage is not reached by 2002. Meeting that goal under that bill is so unlikely, Aaron says, that the deadline is merely ``and artful dodge.''