A health-care reform bill drawn largely from President Clinton's plan has a good chance of passage in the next year, but Clinton's controversial tight spending controls will probably be changed by Congress, two Republican health policy experts said last week.

"Fifty-six percent of the public say we need a complete overhaul of the health system, and they're scared about losing their health insurance. That is what's driving this issue," said Stuart Altman, a Brandeis University professor and former Nixon administration health economist.

Altman, who spoke in New York City at a health-care finance symposium sponsored by AMBAC Inc., also served on President Clinton's health-care transition team. He said Clinton's aggressive health-care reform platform was a major reason the President was elected a year ago.

Reform will "bring some bitter pills for the health-care industry, but good things for the American public," Altman said. Reform is now supported not only by most middle-class Americans, but by the majority of businesses that have been forced to Pick up the tab for the emergency care increasingly provided to the nation's 37 million uninsured people, he said.

"We have pushed our voluntary insurance system to its limits," Altman said. "Ford (Motor Corp.) will spend 20% of its payroll on health care this year, and at GM it's up to 25% of payroll. This is not a fringe benefit anymore. It's gotten out of hand."

Gail Wilensky, a health economist and a White House health adviser during the Bush administration, told the AMBAC symposium that she also hopes to see health-care reform pass in the next year.

"I think there is a chance, although I'm more pessimistic than some because we have a very volatile public," Wilensky said, pointing to recent declines in opinion polls in the once strong support for health reform. "This is not a slam dunk, no matter what you think about the bipartisanship" that has been displayed so far, she said.

Unlike Altman, Wilensky predicted that the all-encompassing Clinton plan -- with its universal coverage and expansion of existing benefits -- would have to be watered down to pass Congress.

"The big bang of health-care reform is not likely -- not with the trouble they had" enacting Clinton's $500 billion budget and economic package this summer, Wilensky said.

Altman said that the Clinton plan was the most likely to pass Congress because the leading alternatives sponsored by conservative Democrats and Republicans fail to guarantee universal coverage -- largely because they lack Clinton's mandatory employer-paid insurance premiums.

Wilensky said the primary problem facing the Clinton plan is the division within the President's own party over the tight controls the plan would place on health-care premiums and federal subsidies, which are aimed at squeezing savings out of the health-care system.

The controls are designed to cut the rate of health-care inflation from more than 10% annually to just above the general inflation rate of around 4% -- a goal which both Wilensky and Altman said was unrealistic.

The deep rift in the Democratic party over such controls is "no small problem" for Clinton, Wilensky said. During the Bush years, the rift prevented Democrats from even agreeing to vote on a health reform plan, she said. Conservative Democrats generally have sided with Republicans in favor of controls, while other Democrats have strongly opposed them.

"So much of the Clinton plan hinges on this control. It will either pass, or Congress will have to seriously scale back the benefits," Wilensky said.

Altman agreed that the cost controls will be the biggest issue in Congress, and he said he was troubled by them. "I've got a real problem with the savings" Clinton is hoping to generate through managed competition, because they may not materialize, he said.

As an adviser to Clinton earlier this year, Altman said he told the President he shouldn't expect to finance the plan primarily with savings from Medicare and Medicaid. Nevertheless, Altman dismissed the competing health plans that have emerged in Congress as less realistic than Clinton's, and said the Clinton plan would only have to be somewhat modified to gain sufficient votes for approval. In particular, the administration must go after the votes of moderate Republicans like Rhode Island Senator John Chafee, who want universal health coverage but at a lower cost.

In the end, Altman predicted Congress would pass a plan with cost containment to appeal to conservative Democrats and Republicans, but without the tight limits imposed in the Clinton plan.

Both Wilensky and Altman held out the possibility that the reform effort could fail if Clinton does not put together a broad enough coalition to support it.

Wilensky said the "worst thing that could happen" is that the Clinton plan would get just enough votes to pass, but the public would react adversely when Clinton president sought to implement it. Congress and the Bush Administration had that experience when they enacted a catastrophic health plan for the elderly, They had to repeal the law the next year in the face of strident opposition from the elderly who had to pay for it.

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