It appeared last week that the final phase of the healthcare reform battle on Capitol Hill will come down to a purely political contest over a single issue: universal coverage.
When the fight is over, President Clinton could face the unsavory choice of signing a bill that fails to guarantee health coverage for all Americans, which he has vowed would be his bottom line, or vetoing legislation that would provide limited relief for the uninsured, according to veteran Capitol Hill watchers.
"The key for Clinton will be to figure out how to compromise without capitulating," said healthcare lobbyist Frederick Graefe. "The key for Republicans is how to make Clinton eat crow on universal coverage" just as former President Bush had to on his promise of no new taxes.
The healthcare reform debate is expected to move to the floor of the Senate and House late this month after the leadership of both chambers draft bills they think could win a majority of support.
After an August recess, a conference committee of House and Senate negotiators will work out differences-which will likely be substantial-between the competing versions. If the compromise passes, it will be sent to Mr. Clinton for his signature.
The process is expected to be as rancorous as its outcome is unclear. Interest groups of all stripes have begun investing millions of dollars and unleashing grass-roots armies to fight the final and most crucial battle. Lawmakers facing re-election, meanwhile, are under pressure to respond to the diverse constituency demands.
In general, a moderate reform bill would be a "gain for Republicans," whose constituents "worry about what government will do to them rather than for them," said polling expert Robert Blendon, chairman of the health policy and management department at the Harvard School of Public Health. For Democrats, whose constituents have counted on them to deliver on comprehensive reform, such an outcome would be a "real loss," he said.
Fueling speculation that Congress ultimately will settle for something less than universal coverage was the recent action by the Senate Finance Committee. Committee members completed work on a reform plan early this month and became the first congressional panel to reject universal coverage financed mainly by mandatory employer-paid insurance.
Unlike two House committees and one Senate panel that had previously drafted reform bills, members of the Finance Committee decided instead to give market-based reforms several years to work, and established an advisory commission to make recommendations to Congress on how to achieve universal coverage if those efforts failed (See chart).
The final product, crafted largely by a bipartisan group of senators on the panel, outraged universal coverage advocates.
Asked what he thought of the Senate bill, William Cox, vice president of the Catholic Health Association, said simply: "Not much. Our view of the Finance bill is that it...does nothing to achieve universal coverage, and universal coverage is the linchpin of healthcare reform," he said.
"The incremental approach is one many in Congress are enamored with because it doesn't cost them much," he added. "But it would not adequately reform the healthcare system and would actually increase costs for the working poor, who need to be helped."
Ron Pollack, executive director of Families USA, a Washington-based healthcare advocacy group, described the Finance bill as the "low watermark in this process.
"What all of the supporters of real health reform need to do is re-energize, refocus the country on key elements of healthcare reform," he said.
But other observers said the Finance bill reflected a centrist policy that ultimately would carry the day in Congress.
"That's where the middle is," said Mr. Graefe, predicting that the Finance Committee's bill reflected where Congress will end up.
For Mr. Clinton, the fate of his presidency could hang in the balance. Some experts said he could sign any bill and declare victory on healthcare reform. But others said he must stick to his guns on universal coverage-even if it means a veto-to retain the allegiance of the left wing of his party, which is still simmering over his endorsement of the North American Free Trade Agreement.
"My sense is that (the president) is going to go all the way on universal coverage," said Richard Pollack, executive vice president of federal relations for the American Hospital Association. "If he compromises, he will lose liberals and the left wing. Those are people who tend to renominate candidates."
According to Mr. Blendon, Mr. Clinton and Congress face a dilemma. Polls show that while the public supports a presidential veto of legislation that falls short of universal coverage, it doesn't support any of the routes for getting there.
"That disconnection is politically dangerous," he said. Policymakers are "stuck with (the public's) belief in a goal, but no way to get there."