Bush, Clinton Health Plans Are Dramatically Different Bush Would Utilize Market; Clinton Seeks a Cap on Medical Costs. US HEALTH-CARE SYSTEM

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THE United States health-care system would likely take a fundamentally different direction under a Clinton administration than in a second Bush term.

Each contender has outlined a very different plan for strengthening the health-care safety net and containing its oppressive costs.

But perhaps the most important difference is that Bill Clinton's plan is far more likely to actually take effect than George Bush's, according to health-policy experts from several viewpoints.

Mr. Bush proposes giving vouchers to the poor of up to $3,750 per family to shop for health insurance. More-prosperous families would get tax credits up to the same amount.

To keep costs down, he would encourage the kind of managed care that health-maintenance organizations provide and rely on competition between such organizations.

Mr. Clinton would require businesses either to supply employees with insurance or to pay into a public plan. The poor would be subsidized in the public program.

To contain costs, he would have a national standards board cap total health-care spending nationally, giving states the option of deciding how to meet their targets.

The plans have "a very important philosophical difference between them," notes Paul Feldstein, a professor of management and health policy expert at the University of California at Irvine. The Bush approach relies on competition to set market rates for health services, with no guarantee that those rates will be low. The Clinton approach sets arbitrary caps, which could lead to other costs, such as longer waits.

But the best-laid plans of the candidates are only part of the picture of what may actually happen in health-care reform.

"If Clinton gets in, we would likely see the kind of plan {Maine Democrat Sen. George} Mitchell has proposed," says Dr. Feldstein. "If Bush gets in, I'm not sure anything would get done."

"It would be hard for me to believe that President Bush would seriously push ahead on health- care reform," says Robert Blendon, a Harvard University political scientist who specializes in health-care policy. "I don't think he cares very deeply about the issue."

Clinton, on the other hand, would "absolutely" have a plan enacted at least by the end of a four-year term, Dr. Blendon says.

"The Bush administration has not made health care reform a priority," says Judith Feder, co-director of the Center for Health Policy Studies at Georgetown University. If Bush is reelected, the country would probably see only some nibbling at the edges of reform of the insurance industry and malpractice law, says Feder, who has advised the Clinton campaign on health policy. …