by Susan Dentzer

        Question: What does the coming health reform debate have in common with dog breeding? Answer: Plenty. President Clinton's plan to provide universal health insurance coverage is about to encounter other breeds on Capitol Hill. Senate Republicans have proposed another big plan to provide universal coverage but through means radically different from Clinton's. Tennessee Democratic Rep. Jim Cooper has a smaller-scale plan popular with centrist Democrats and Republicans. A few other lawmakers are strutting around with smaller versions yet -- plans that would make comparatively modest reforms and enable more Americans to buy and keep broad private health coverage. Somehow or other, these different breeds will mate over the next few months. And if a final health reform plan is born later this year, one strange-looking mutt will surely result. 

        A reform bill is scheduled to go to the floor of the House of Representatives for debate by the end of May, with Senate action to follow. The White House wants a final bill ready for the president's signature by the end of July, but there is a good chance the final vote could take place just weeks -- or even days -- before congressional elections in November. 

        Nobody expects any of the six major competing reform plans, including Clinton's, to survive this process intact. Nonetheless, in the Democratic-controlled Congress, the president's package is the starting point; the question is how it will be reshaped along the way. "We plan to do nothing for the next six weeks but sit in a room and talk about the president's bill," says Democratic Rep. Jim McDermott of Washington, a member of a key House Ways and Means health subcommittee and sponsor of a rival plan to provide everybody with Canadian-style, taxpayer-funded public health insurance. In fact, even though more than 90 House Democrats have endorsed this "single payer" plan, McDermott and his Senate co- sponsor, Minnesota Democrat Paul Wellstone, admit that their best hope now is to amend the Clinton plan in several key ways. Among them: expanding the president's proposed benefits package to include broader mental health coverage and assuring that patients will be able topick their own doctors freely without incurring any financial hardship. 

        Clinton insists that he is flexible on reform's details, aside from his demand for universal coverage. Yet when Congress begins tinkering with its pieces, the whole structure could collapse -- and it's not clear that lawmakers could agree on an alternative. Here are the three biggest issues at the heart of the struggle and how the competing plans deal with them: 

        Universal coverage. A top concern is whether -- and when -- health reform should provide health insurance for virtually every American. At any given time, some 15 percent of the U.S. population -- about 38 million people -- is now without insurance. Clinton's plan is designed to insure all but about 2 percent of Americans by 1998. The key exception: States would be allowed to find ways to pay the health expenses of the homeless and of migrant workers other than by giving them insurance packages. 

        Nearly all Clinton's competitors proclaim the importance of universal coverage as a long-term goal. But, in fact, the camps are split between those who simply want to make private health coverage more affordable and accessible for more people and those who want ironclad guarantees and definite sources of funding to ensure that almost everyone will have health insurance. In general, those in the first camp include the plan sponsored by Representative Cooper and a House Republican proposal introduced by Minority Leader Robert Michel of Illinois. Those in the second camp include Clinton, the single-payer advocates and Republican Sen. Don Nickles of Oklahoma, whose plan would close the loophole in the tax code that makes health insurance a nontaxable benefit and use the savings to channel tax credits to individuals in order todefray coverage costs. Somewhere in the middle lies the plan endorsed by Republican Sen. John Chafee of Rhode Island, which proposes redeploying huge savings from the two major government health programs, Medicare and Medicaid, to gradually extend coverage to virtually all Americans by 2005 -- but only if those savings actually materialize. 

        Among those in the first camp, the plan sponsored by Representative Cooper and his Senate colleague, Democrat John Breaux of Louisiana, takes the concept of health care accessibility the furthest. Like most other reform plans, Democratic and Republican, theirs would rewrite insurance laws to ban practices like denying coverage to people with pre-existing medical conditions. New insurance purchasing pools known as "health alliances" would be set up so that the jobless, the self- employed and small businesses and their workers could obtain coverage at the discounted rates available to larger firms. 

        But unlike the Clinton plan, theirs does not require companies to contribute to covering their workers. Instead, Cooper's plan would pay for insuring all the poor; allow those who buy coverage for themselves to take tax deductions of 100 percent of premiums, and subsidize coverage for people earning up to 200 percent of the poverty level, or about $29,530 in today's terms. The bottom line is that the plan would probably extend coverage to at least 20 million more Americans, leaving perhaps an additional 20 million without assured coverage. 

        Cooper says he agrees with Clinton that universal coverage is important. But he argues for getting as much as possible out of pro-competitive changes in the insurance market before enacting the president's more draconian reforms. "Universal coverage isn't like a light switch; it's like a dimmer switch that you turn on slowly," Cooper says. "Our bill is 80 percent bright, without blowing any fuses." All the same, he's now negotiating with Clinton on a compromise to achieve something closer to universal coverage than his own plan realizes. One possibility is to postpone the president's timetable for universal coverage by a few years so that reform costs less upfront. That's the strategy behind Chafee's plan for getting to universal coverage by 2005. But setting a target date so long after Clinton leaves office could be politically risky for the president, since it would be seen as an empty promise. Then there's the grim lesson of Massachusetts, which passed a phased-in universal plan under then Gov. Michael Dukakis in the late 1980s -- only to see it scuttled amid the state's fiscal crisis several years later. 

        Paying for reform. Getting universal coverage depends on two key questions: How much money is Congress willing to raise, and how do lawmakers propose to collect it? Clinton's answer is to muster $409 billion from 1995 to 2000 largely through savings in government health programs and higher taxes on tobacco. But another chunk of money for his plan would come from employers, who overall would pay about 7 percent more than they are currently projected to spend on employee health benefits from 1995 to 2000, according to an analysis by Lewin-VHI, a health- policy consulting firm. What's more, Clinton's plan, along with Cooper's and Chafee's, embraces an insurance-pricing system known as "community rating," in which everyone in a geographic area pays the same rates for health insurance. In effect, this means that employers and workers would heavily subsidize the coverage of nonworkers, who tend to be older and sicker than the rest of the population. 

        Other reform plans like Cooper's and Chafee's mimic Clinton's in proposing to use savings from government health programs to help fund broader coverage. But they reject on political and ideological grounds his requirement that companies pay for their workers. Chafee's Senate Republican Task Force plan substitutes an "individual mandate" -- a requirement that by 2005, all American citizens obtain health coverage much as drivers are required to have auto insurance. Like Cooper's plan, Chafee's would allow people who paid for their own coverage to deduct 100 percent of the cost up to a preset limit. It would also subsidize coverage for individuals, with these subsidies phased in so that even those with incomes up to 240 percent of the federal poverty level, or about $35,430 in today's terms, would receive them by 2005. 

        Still, a marriage could be in the works between the Clinton and Chafee plans, combining the employer and individual mandates. Since many of the nation's small businesses ferociously oppose the employer mandate, one option is to exempt firms with fewer than 25 or 50 workers from complying with it. People who worked for those small firms would still be subject to an individual mandate. But as in Chafee's plan, they could deduct the cost of coverage if they paid for it themselves or obtain subsidies if their income was low. Larger firms would be subject to the employer mandate, but the vast majority of them now cover their workers anyway. 

        Some Clinton advisers think this hybrid could work. While small- business groups would probably continue to fight the employer mandate, their opposition would be blunted by exempting the smallest, most vulnerable firms. A new U.S. News poll suggests potentially broad public support; while 19 percent of those surveyed favored an employer mandate and 10 percent an individual mandate, 62 percent said they would support a combination of the two. Moreover, the hybrid approach could be technically simpler to administer than Clinton's plan, which includes a complex scheme to channel subsidies to small businesses based on their size and average wage. 

        Containing costs. A strange hybrid in its own right, Clinton's plan struggles to contain costs in seemingly conflicting ways: Parts of his plan would spur competitive market forces to rein in health outlays, while other pieces are heavily regulatory, anticompetitive and bureaucratic. For example, the president proposes to hold price increases in private health insurance premiums to the level of general inflation by 1999; that's less than half the pace at which they're now rising. Yet, there are widespread fears that such de facto government price controls could actually thwart the very market forces Clinton hopes to unleash. 

        Other reform plans rely on the market to rein in costs in the private sector, and their backers reject Clinton's premium limits. "The votes aren't there for price controls," asserts Nickles. Yet the insurance price limits are central to Clinton's financing scheme; without them, the price of his standard insurance package could rise at least 25 percent, the government would have to come up with billions more in subsidies from 1996 to 2000, and private firms would spend as much as $123 billion more over that period to cover their workers. Thus, if lawmakers strip the price controls out of Clinton's bill, they'll have to come up with far more money -- read taxes -- or even further postpone or abandon the goal of universal coverage. 

        Major skirmishes also lie ahead in other areas. Virtually all other reform plans reject Clinton's notion of large,bureaucratic health alliances through which nearly three fourths of the population would obtain health coverage. Chafee, for example, wants to make participation in them voluntary for workers and businesses. 

        There will also be a tug-of-war over defining what benefits Americans should expect in their insurance packages. And Republicans like Texas Sen. Phil Gramm, who introduced a reform plan this week, will fight for inclusion of so-called medical savings accounts, or MSAs. Under this approach, workers could choose between comprehensive benefits plans offered to them by their employers or cheaper "catastrophic" insurance packages. If they picked the latter, they could set aside the difference tax free in MSAs, using the money to pay their high insurance deductibles and other out-of-pocket medical expenses or save the money for retirement. 

        Clearly, the run-up to reform is now officially over. It's time to decide how much any changes should cost, who gets covered, who wins and who loses. 

        THE HEALTH SECURITY ACT President Clinton's plan is far and away the most detailed of all reform proposals now in Congress. 

        Chief sponsors: Rep. Richard Gephardt, Mo., and Sen. George Mitchell, Maine. 

        The plan: Coverage extended through a mandate on employers to contribute, insurance reforms, big new health alliances. 

        Universal coverage? Yes, by 1998, except for undocumented immigrants. 

        Uniform benefits package for all? Yes; fairly generous package set first by Congress, then updated by national health board. 

        How would a currently uninsured family fare in 1998? A mother of two with $20,600 income works at a 40-person firm (average wage $20,000). Value of family's insurance premium estimated at $4,983. Family's premium is $803 a year; employer pays $1,420 after $2,760 government subsidy. 

        How would a currently well-insured family fare in 1998? Family with two kids and two working parents earning $80,000 obtains coverage with actuarial value estimated at $5,581. Family pays $1,116 toward premium; each employer pays $3,174. (Figures don't add up because of complex funding formula for covering two-worker families.) 

        Where does the money come from? $409 billion raised through 2000, largely from Medicare, Medicaid cuts, higher tobacco taxes. Employers could pay 7 percent more than currently projected. 

        Part of plan most likely to be adopted: Prescription drug coverage for Medicare beneficiaries. 

        Part of plan least likely to be adopted: Tough price controls on insurance premiums.

        THE AMERICAN HEALTH SECURITY ACT More than 90 House Democrats back a Canadian-style plan to provide taxpayer-funded health coverage to every American.

        Chief sponsors: Rep. Jim McDermott of Washington and Sen. Paul Wellstone of Minnesota. 

        The plan: The U.S. government would collect payroll taxes, funneling the money to states to provide coverage. 

        Universal coverage? Yes, by 1995, except for undocumented immigrants. 

        Uniform benefits package for all? Yes, determined by Congress. Includes long-term care. 

        How would a currently uninsured family fare in 1998? A mother with two kids, $20,600 in income, working at a small firm, pays $127 annually for coverage with no other expenses. Her employer pays $824. 

        How would a currently well-insured family fare in 1998? A family with two kids and two working parents and $80,000 in income pays $1,293 for coverage with no out-of-pocket expenses. If the parents work for big firms, their employers pay $6,720. 

        Where does the money come from? Individuals pay a 2.1 percent tax on all income. Firms pay a payroll tax rate of 4 percent or 8.4 percent, depending on the company's size and average wage. New taxes on handgun sales and higher tobacco taxes. Medicare and Medicaid folded into plan; states pay 15 percent of program's overall cost. 

        Part of plan most likely to be adopted: Individuals' ability to pick own doctors without financial penalty. 

        Part of plan least likely to be adopted: Its requirement that taxpayers pay for all health insurance.

        HEALTH EQUITY AND ACCESS REFORM TODAY ACT The plan drafted by a Senate GOP health task force would provide universal coverage by 2005 -- but only if savings show up. 

        Chief sponsors: Rep. Bill Thomas of Calif. and Sen. John Chafee of R.I. 

        The plan: All Americans would be required to purchase health insurance by 2005, with subsidies and tax breaks for many. 

        Universal coverage? Yes, for all but undocumented workers by 2005, assuming enough savings are realized in the system. 

        Uniform benefits package for all? A commission would set benefits for "catastrophic" and comprehensive health plans; Congress could accept or reject. Firms with more than 100 workers would have to offer these plans. 

        How would a currently uninsured family fare in 1998? A mother with two kids and $20,600 in income wouldn't get subsidies until year 2000. A family could deduct 100 percent of premiums from taxes, depending on the price of the plan. 

        How would a currently well-insured family fare in 1998? A family of four with employer-paid coverage and $80,000 in income wouldn't get government aid. If it had a fairly expensive health plan, it might pay taxes on a portion of the benefits. 

        Where does the money come from? Medicare and Medicaid cuts of $363 billion through 2003; more tax revenues from closing health benefits loophole. 

        Part of plan most likely to be adopted: A requirement that individuals purchase insurance. 

        Part of plan least likely to be adopted: Caps on noneconomic damages in malpractice lawsuits.

        MANAGED COMPETITION ACT This plan to unleash market forces to contain costs draws support from moderates, insurers and drug companies. 

        Chief sponsors: Rep. Jim Cooper, Tenn. , and Sen. John Breaux, La. 

        The plan: Insurance reforms and purchasing pools would drive down the price of coverage. Subsidies and tax breaks would further cut costs. 

        Universal coverage? No. It aims for "universal access," or affordable coverage for everyone. 

        Uniform benefits package for all? A national commission would set benefits for a standard comprehensive package that all insurers must offer. Congress could accept or reject. 

        How would a currently uninsured family fare in 1998? A working mother of two with $20,600 in income would get a government subsidy equal to half her family's insurance premium. She could also deduct the other half from her taxes. 

        How would a currently well-insured family fare in 1998? The impact on a family of four with $80,000 in income would vary with the cost of the insurance it wants. The cheaper the plan, the greater the share of premium the family could deduct from its taxes. 

        Where does the money come from? Medicare cuts of $40 billion over five years; all Medicaid monies steered to subsidies. Limits on employers' deductions for health benefits raise $79 billion. 

        Part of plan most likely to be adopted: Market sets price for health premiums without price controls. 

        Part of plan least likely to be adopted: Its premise that broadened coverage can result without mandating that firms or individuals pay for it.

        AFFORDABLE HEALTH CARE NOW A low-budget House GOP plan focuses on insurance reforms but minimal structural change. 

        Chief sponsors: Rep. Robert Michel, Ill. , and Sen. Trent Lott, Miss. 

        The plan: Market forces and private purchasing pools would lower costs of coverage; states would also set up special pools for uninsured. 

        Universal coverage? No. The goal is improved access to insurance.

        Uniform benefits package for all? A national insurance commissioners panel would determine a median plan of benefits and its actuarial dollar value, which all businesses would have to offer. 

        How would a currently uninsured family fare in 1998? A working mother of two with $20,600 in income could be covered through a state pool. The state could also purchase Medicaid coverage for family. It's not clear what the family would pay. 

        How would a currently well-insured family fare in 1998? A family of four with $80,000 in income wouldn't get any special help, although premiums could be more stable. The family could elect catastrophic insurance, depositing rest of employer contributions into a medical savings account (MSA) for other health or retirement expenses. 

        Where does the money come from? Small cuts in Medicare; savings from federal retiree programs. States could put Medicaid enrollees in HMOs and use savings to cover uninsured. 

        Part of plan most likely to be adopted: MSAs.

        Part of plan least likely to be adopted: State insurance pools for the uninsured.

        CONSUMER CHOICE HEALTH SECURITY ACT This GOP plan provides a menu of insurance plans for everybody. 

        Chief sponsors: Rep. Clifford Stearns, Fla., and Sen. Don Nickles, Okla.  

        The plan: Nixes loophole that makes health benefits nontaxable; savings used for tax credits based on a family's income and health outlays. 

        Universal coverage? Backers say yes.

        Uniform benefits package for everybody? No, but Uncle Sam and insurance commissioners draft standards for different types of plans. 

        How would a currently uninsured family fare in 1998? A working mother of two with $20,600 in income gets a tax credit and low- income subsidy worth $3,170. If the family buys a health plan with a $4,200 overall premium, it pays $1,030. 

        How would a currently well-insured family fare in 1998? A family of four with $80,000 income swaps broad employer-provided coverage for a cheaper plan. Its gross income rises $7,040, assuming employer pays wages in lieu of insurance. The family buys catastrophic plan for $3,800 and sets aside up to $4,500 in a medical savings account, to be used only on health expenses. Family gets a $2,075 tax credit; after-tax income rises $2,144. 

        Where does the money come from? Medicare and Medicaid savings of $139 billion by 1999; $300 billion in taxes from closed health care loophole. 

        Part of plan most likely to be adopted: Its provision to allow Americans different types of plans. 

        Part of plan least likely to be adopted: Antitrust protections for physicians.