Way Ahead of Bill

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Why wait for Bill Clinton, or Hillary either? They are taking what seems like forever to come up with a national health-care plan. And when they do, Congress may stall some more and change the plan beyond recognition. So states, companies and even the medical profession are pushing ahead with their own plans to cut costs, streamline care and extend coverage to more of the uninsured. "If anyone believes we are waiting for the Administration's final package or for congressional action on that package, he's wrong," says Roger Tracy, director of community-based programs at the University of Iowa College of Medicine. "Reform is alive and well and moving very swiftly."

To patients, the reforms may mean a more restricted choice of doctors, or else paying a greater portion of the bill. Many corporate plans seek to steer patients to physicians who join a health-maintenance organization (HMO) or so- called preferred-provider organization (PPO) by cutting reimbursements to employees who insist on consulting "outside" doctors. But this is supposed to be offset by other benefits: fewer and simpler (or maybe no) maddening reimbursement-claim forms to fill out, to cite one. To the uninsured, the reforms provide a chance to buy policies now unavailable. Many states, for example, are sharply restricting the ability of insurance companies to turn down applicants because of a "pre-existing condition" (insurance jargon meaning they already have an ailment that is expensive to treat, perhaps kidney disease or multiple sclerosis). And for everybody -- patients, taxpayers, state officials, business executives -- the reforms promise, eventually at least, a slowdown in the relentless rise of medical costs that keeps kiting up insurance premiums and patients' bills and biting into state budgets and company profits.

The grass-roots efforts, however, form a crazy quilt of programs varying widely in generosity and effectiveness. There are companies whose idea of "reform" consists of slashing, or even denying, health benefits to retired employees (companies must now show the estimated cost of those benefits on their balance sheets as a liability, sometimes of embarrassing ; size). Some states have enacted only timid reforms, and others are being forced by a budget squeeze to pare down reforms put on the books in more prosperous times. Massachusetts, to take one prominent example, has delayed until 1995 some important steps in a comprehensive reform plan, enacted in 1988, that were originally supposed to be phased in over four years. Some companies worry about having eventually to deal with 50 different sets of health benefits, regulations and taxes. And some legislators fear they could penalize their states by enacting comprehensive medical reforms if taxes rise enough to push some businesses to relocate.