Is universal health care still in the works?

This time there's no sign of global budgets, alliances, or even health security cards. No Byzantine flow charts. Not even a discouraging word from "Harry and Louise," the infamous insurance industry spokescouple. But make no mistake: Health care for all is closer to reality now than it was when President Clinton unveiled his sweeping initiative in his 1994 State of the Union Address.

Although an alliance between insurance companies, employers, and congressional Republicans doomed his original proposal, Mr. Clinton understood that these critics attacked his plan for its impracticality - without challenging his basic assertion that government should guarantee the right to health coverage.

This tactic left conservatives and other opponents vulnerable to a more piecemeal strategy.

In a September 1997 speech to the Service Employees Union, Clinton summarized his new approach to reform: "If what I tried before won't work, maybe we can do it another way. That's what we've tried to do, a step at a time, until we eventually finish this."

By offering it in installments, Clinton has been able over the last four years to enact a significant part of his original health care program. The first installment traces back to early 1996, when Sens. Nancy Kassebaum (R) of Kansas and Ted Kennedy (D) of Massachussetts co-sponsored a bill allowing people who lost or changed their jobs to keep their health insurance. After deciding that opposing it was not worth the political damage, Congress relented and passed it. Clinton signed the bill into law.

That same year, Clinton effectively raised child immunization rates to an all-time high.

Then in 1997, he signed legislation representing the single largest investment in health care for children since 1965 - the $24 billion Children's Health Insurance Program (CHIP), which provides coverage for up to five million poor children.

In a speech at the White House in January 1998, President Clinton proposed the largest expansion of Medicare in 25 years, offering coverage to early retirees at age 62, and the opportunity for displaced workers at age 55 and older to buy coverage under Medicare.

In his FY2000 budget proposal, Clinton called for a long-term care initiative to provide respite, home care services, and information and referral assistance to the approximately 250,000 families caring for elderly relatives who are identified as chronically ill or disabled.

The budget also offers tax credits to encourage small businesses to provide health insurance benefits; earmarks $1 billion for comprehensive health care delivery systems for the uninsured; calls for Medicare clinical trials to give more Americans access to cutting-edge cancer treatments; and increases funding for Ryan White HIV/AIDS treatment grants, among other measures.

In January the president endorsed a proposal by Sens. Jim Jeffords (R) of Vermont and Kennedy that would provide $1.2 billion in health care incentives to help states allow disabled workers to buy insurance through Medicaid even if their incomes would ordinarily make them ineligible. And last week, the President called for expanded prescription-drug coverage under Medicare.

Of course, critics abound. Conservative commentator Robert Novak refers to Clinton's creative efforts to achieve universal health care as "covert plans for big government." House majority whip Dick Armey (R) of Texas calls Clinton's progress "socialized medicine on an installment plan."

Clinton's success has not been unqualified. Long-term health care challenges remain. The solvency of the Medicare system, for example, dangles on perhaps overly optimistic assumptions about future budget surpluses, not to mention the GOP's zeal for a "10-year, trillion-dollar tax cut" that would blow a hole in revenues needed to shore up the system.

The fact that many of his initiatives have passed or enjoy broad public support shows Clinton has again managed to grab victory from the hands of defeat.

A master of taking the best ideas of his opponents and making them his own, perhaps Clinton's reinvigorated health care activism owes to Louise's oft-muttered kitchen-table mantra: "There's got to be a better way."

*Michael Holtzman is vice president of Shandwick International, a public affairs firm. He was press secretary to the Council on Foreign Relations from 1995 to 1997.