As Health Debate Crystallizes, Congress Awaits `Vote of Year'

A WASHINGTON truism: Politics is not a battle over the answers to modern problems - but over defining the questions.

Much of the campaigning and debate during the rest of the summer and fall will attempt to frame the choices Congress faces on health-care reform and how the public sees them.

The next few weeks are the time of the big crunch in health-care reform, when House and Senate leaders are tasked with producing a single bill with majority support.

Members will be casting what could be the vote of their careers in the teeth of elections in November. They will face a confusing and dangerous picture of voter attitudes. Fully 60 percent of the public will vote against a member who opposes major health-care reform, according to a Times Mirror poll last week.

But which reform? Polls show no majorities behind the details of any plan.

President Clinton and his Democratic allies hope to frame their health-care reform plan as the only practical option to no action at all.

To claim that middle ground, he began to distance himself this week from the most unpopular features of his own plan. He shifted as well to a tone of open-minded pragmatism, in contrast to the partisan and ideological color his health plan has taken on in the eyes of many voters.

``The question is what are we going to do that works?'' Mr. Clinton said to the nation's governors on Tuesday, making clear that some of the key remaining elements of his own plan are the only ones likely to hold down medical costs for ordinary Americans.

In practical political terms, Clinton advisers argue that most citizens are not aware that Republicans have developed alternative plans and that floor debate on Capitol Hill in coming weeks will center around the plans designed by the Democratic leadership.

So a vote against the leadership bills in the House or Senate will be seen by the public as a vote against health-care reform, according to unofficial White House pollster Stan Greenberg.

Republicans and many moderate Democrats are working to reshape that perception. They hope to frame the question before Congress this summer as a choice between an expensive, big-government plan and their less intrusive, less ambitious version.

Republicans are loathe to appear in the role of obstructing reform. Perhaps for that reason, Senate Minority Leader Bob Dole (R) of Kansas suggested this week that Congress might stay at work right through the August recess until the reform bills are voted through or voted out.

Some are guessing that wary voters would be pleased to have Congress fix some of their most worrisome problems by banning insurers from refusing to serve people with preexisting health problems and by making insurance policies portable from job to job.

Alternative plans like Mr. Dole's would reduce the ranks of the uninsured by subsidies and tax credits for lower-income people who are currently not poor enough to qualify for Medicaid but not affluent enough to afford available health insurance.

The practical problem for Republicans and conservative Democrats is getting their bills to the floor where they can be debated and voted on. None of them was reported out of committees, except a bipartisan - but mostly Democratic - bill that emerged from the Senate Finance Committee. They are relying on the Democratic leadership to allow consideration of their bills on the floor.

The greatest advantage for the conservatives is the unpopularity of Clinton's plan. Most people are fuzzy about the details of Clinton's reform proposal, but by now they associate it strongly with big-government bureaucracy.

In the Times Mirror polls released last week, the public was split dead-even between those who would vote for or against a member of Congress who supported the Clinton plan.

A slim majority, however, would vote for a member who supported an unspecified alternative plan.

In beginning to move away from the stigmatizing elements in his own plan, Clinton emphasized this week to the governors that he has scotched its mandatory health alliances, opened more flexibility for states, and eased the burden on small businesses.

He also began to speak in more practical terms about what universal coverage means - upwards of 95 percent, not 100 percent, and phased-in gradually.

Immediate, universal coverage has consistent majority support from the public, but the public has shown little enthusiasm for how to pay for it. Clinton argues that requiring employers to pay most of the bill and requiring everyone, or nearly everyone, to be insured is the only way to control costs.

Subsidies and tax credits can have the unintended effect of encouraging employers now insuring their employees to drop coverage and let the government pick up the tab, Clinton says.