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WASHINGTON-With a series of legislative successes behind it, the Clinton administration now is targeting additional areas to expand health care coverage.
President Clinton last week put forth his health care agenda, specifying areas for legislative action and areas where he believes there are problems but where he has not endorsed a specific remedy.
Legislation President Clinton said he wants passed would:
Ban so-called drive-through mastectomies. President Clinton described as "horrifying" situations in which women are denied coverage for an overnight stay in a hospital after a mastectomy. He said Congress should act just as it enacted legislation last year that requires health plans to offer at least 48 hours of inpatient coverage after a normal birth and 96 hours after a Caesarean section.
Ban so-called gag rules, in which some managed care plans have barred providers from discussing, among other things, alternative treatment options and costs to members.
In addition, President Clinton identified two other health care areas-of huge potential significance to employers-that may need federal action, though he did not offer or recommend specific remedies. Those areas are:
Early retiree health care coverage. President Clinton said something needs to be done to assure coverage for employees who retire before 65 and are not yet eligible for Medicare.
"What about all those people who retire at age 55 and lose their employer-based health insurance and can't draw Medicare until they're 65?" President Clinton asked.
Subsidized health care coverage for the unemployed. While the federal COBRA law allows employees who lose their jobs to continue their group health care coverage by paying 102% of the group rate, COBRA premiums may be too expensive for the unemployed to pay.
"What about all the people who have a right to keep their health insurance when they're between jobs, but after they've been without a job for a certain amount of time they . . .can't afford it," President Clinton said.
In his speech, delivered before the Service Employees International Union, President Clinton made clear that he has learned a lesson from his disastrous foray in the health care arena in 1993, when his plan to overhaul the nation's health care system went down in flames.
The way to achieve change in the health care field, the president said, is incrementally. "We've got to do it right so we can go on to the next step and the next step and the next step," he said.
That incremental approach has, during the last year, resulted in the passage of several major pieces of health care legislation.
Last year, for example, President Clinton threw his support behind and gave a jump start to legislation-later enacted-that curbs the use of pre-existing medical condition exclusions.
The administration also was an enthusiastic backer of measures also passed in 1996 that mandated minimum inpatient coverage for maternity stays and achieved limited mental health care benefits parity.
Its most recent health care legislative triumph came in late July, when Congress passed the so-called "KidCare" measure, in which the federal government will give the states about $24 billion in block grants for the states to use to establish programs providing health care coverage to children in low-income families who are uninsured.
This incremental approach to expanding health care coverage has served the administration well, experts note.
"One can get a lot done one step at a time," said Frank McArdle, a consultant with Hewitt Associates L.L.C. in Washington.
Stuart Brahs, vp-federal government relations at The Principal Financial Group in Washington, said, "What the administration could not achieve in a broad way, it now is trying to achieve bit by bit."
"The administration's overall objective has not changed: expanding health care coverage. What has changed is its realization that it makes more sense to fight one battle at a time rather than an entire war," concurred Sylvester Schieber, director of Watson Wyatt Worldwide's Research and Information Center in Bethesda, Md.
Areas President Clinton identified as potential problems-affordable health care coverage for the unemployed and coverage for early retirees-have their origins in earlier proposals.
Since 1995, President Clinton has said something needs to be done to provide affordable transitional coverage for employees who lose their jobs. He earlier suggested federal subsidies of COBRA premiums for the low-income unemployed. Despite the long period of discussion, the administration never developed a specific legislative proposal.
In 1993, though, the administration did develop as part of its broader health care reform initiative a proposal in which the federal government would have assumed 80% of the cost of health care coverage for retirees age 55 through 64.
That proposal was widely derided as poor public policy and little more than a political payoff for organized labor's support during the 1992 presidential campaign.
Washington benefit observers speculate, though, that the administration has something very different in mind. Rather than support a government subsidy, the administration might propose legislation that would require employers to expand eligibility for COBRA for early retirees so that retirees could hang onto COBRA until they were entitled to Medicare at 65.
"It looks like a COBRA extension," said Mr. Schieber of Watson Wyatt.
Under the COBRA statute, employees who quit or are laid off-regardless of age-can keep COBRA coverage for 18 months. Employees' spouses who lose coverage because of the death of the employee or divorce or marital separation can keep COBRA coverage for up to three years.
Legislation introduced in 1990 by a group of Democratic congresswomen would have allowed individuals age 50 or older who lost group health care coverage to purchase COBRA coverage for up to 15 years-when they would have been eligible for Medicare-or until they obtained coverage from a new employer's health care plan. But that measure died amid stiff employer opposition.
Another possible approach to help early retirees obtain health insurance would be to allow them to purchase coverage through the Medicare program and waive the normal age 65 requirement for coverage, Mr. McArdle said.
While acknowledging-in hindsight-that his earlier effort to develop and get passed a sweeping health care reform measure was too much to accomplish at one time, President Clinton said he does not regret he launched such an effort.
"I have to tell you, though, a lot of times in my life I've gotten beat trying to do something I thought was right. And I prefer that than not trying in the first place. I'm glad I tried (on) health care," he said.
Repeating a theme frequently made during his 1993-1994 reform, President Clinton said the failure to achieve universal coverage adds to costs as the uninsured do not receive adequate preventive or primary care and end up receiving too many services in high-cost emergency rooms.
But rather than trying to address all health care problems at once, reform can be best achieved a step at a time, President Clinton said. "Maybe we can do it in another way. That's what we're tried to do, a step at a time until eventually we finish it," he said.