WASHINGTON — What if they had a health-reform debate and Congress said no?
When President Clinton took office, many Americans assumed that sweeping changes in the health insurance system would be part of his legacy.
Now it seems just as likely that the whole effort could collapse in Congress, brought down by election-year politics and a widespread fear that the prescriptions for reform may make things worse, not better.
In Washington, the implosion of health reform would register in terms of political careers made and broken, interest groups that won or got beaten, congressional seats gained or lost.
But for average Americans, it would mean getting stuck with the consequences of a problem that wasn't solved.
"The two big problems which put this issue on the agenda - the uninsured and rising health-care costs - will still be there," said Drew Altman, president of the Kaiser Family Foundation, a California-based health philanthropy.
In the absence of reform, experts predict that large numbers of uninsured Americans would become a permanent reality. The uninsured would probably find it harder to get charity care, as paying patients pressure hospitals and doctors for discounts.
The majority of Americans, those with employer-provided coverage, would see a continuing trend toward limited choices and higher costs. Government insurance programs for the elderly and the poor would face increasing cost pressures that could lead to cuts in services.
Health-care inflation - lower now than in the '80s - would continue to exceed the rate of increase in overall prices. Health spending would steadily approach one-fifth of the gross domestic product. It now stands at about one- seventh.
On the other hand, many states would continue efforts to correct insurance problems, such as the denial of coverage to people with health conditions. State-chartered insurance purchasing cooperatives could make affordable coverage more available to small businesses. Finally, large corporations would keep searching for ways to deliver cost-efficient, high-quality care to their employees.
Sooner or later, Congress would probably be forced to deal with health reform again. Only this time, the problems of diminishing coverage and rising costs could be harder to tackle.
"Even if things only get a little worse, it will become more difficult every year to solve these problems," said Marilyn Moon, a health economist with the Urban Institute think tank. "It could mean paying more in taxes, or more stringent cost controls."
Here's a look at what could happen if Congress can't agree:
THE UNINSURED. Although most people who lose their health insurance regain coverage within months, about 17 percent of Americans under age 65 - nearly 39 million - are uninsured at any given time.
Bill Custer, a senior analyst with the Employee Benefit Research Institute in Washington, said the numbers reflected a long-term deterioration in employer-provided coverage. "It is going to be a constant upward trend," said Custer.
Improvement in the economy could slow the rate of increase in the number of uninsured, but many new jobs do not come with insurance.
When they get sick, the uninsured may find it harder to get free care. Hospitals and doctors, faced with demands for discounts from insured customers, would have less to spend on charity cases.
Numerous statistical studies have shown that the uninsured are diagnosed later for treatable diseases, get sicker and have a higher risk of premature death.
"All employers are seeking discounts," said Moon, "and one of the ways they do it is to make sure that providers aren't passing on the cost of charity care."
WORKING FAMILIES WITH INSURANCE. Employers and insurers will continue the managed-care revolution, under which the open choice of doctor that came with traditional insurance has been restricted.
Businesses will continue to try to shift more of the rising cost of insurance to their workers. Studies have shown that many large employers are already paying less than the usual 80 percent of premiums.
"One year your choice is cut down, the next year your contribution goes up," said Irwin Redlener, a New York pediatrician who worked on the White House health task force.
For workers afraid about a lapse in insurance when they switch jobs, the situation will vary from state to state. They could also purchase transitional coverage from their old employer, provided they pay the full cost.
THE ELDERLY AND THE POOR. The Medicare health insurance program for the elderly and the Medicaid program that serves the poor would continue to come under pressure to reduce costs.
The elderly would not receive new prescription-drug coverage and long-term- care benefits proposed by Clinton and congressional Democrats.
Custer predicts that the gap between what private insurers and government programs pay doctors and hospitals will continue to grow. Many doctors do not accept Medicaid patients now because it pays so little. There's concern that Medicare could run into the same problem.
On average, Medicare now pays doctors 59 percent of what private insurance pays, while Medicaid pays 47 percent. Medicare pays hospitals 89 cents on every dollar of hospital costs, while Medicaid pays 91 cents. By comparison, private insurance pays $1.31 on the dollar.
"There will be a continued polarization between privately and publicly insured individuals," said Custer.
HEALTH COSTS. Health-care inflation is at a 20-year low, but analysts are divided over the cause. In any event, prices for health services are still going up at roughly twice the rate of overall inflation.
Some economists believe lower health-care inflation is a sign that managed care and other cost-control measures are finally starting to work. Others say that hospitals, doctors, drug companies and insurers are artificially holding down prices until the danger of government controls has passed.
Lower prices for medical services may not necessarily reduce health spending, which is approaching $1 trillion a year. That's because doctors and hospitals can get around lower prices by performing more services.
"The real issue is spending," said Altman. "And under any scenario that anybody has spun out, it's going to continue to rise."
