ASHINGTON - As he surveyed the health care industry six years ago, and considered ways to improve it, President Clinton proposed eliminating Medicaid, the federal-state insurance plan for the poor and disabled.
It is a huge program, covering 35 million people and one of every three births. But the group that designed Clinton's health plan viewed Medicaid as deeply flawed: Its rules are confusing, and many eligible people do not enroll.
It also segregates the poor in their own health system, leading to lower quality care.
Now, years after the president's Medicaid plan died, along with his health care overhaul, a big-name Democrat is building a presidential campaign on a similar idea.
But in a twist, the new proposal comes from former senator Bill Bradley. And its chief critic is a man who once backed Clinton's idea, Vice President Al Gore.
Medicaid, in fact, has been one of the most serious points of contention between the two candidates. Gore says Bradley's approach could disrupt care for the needy; Bradley says Gore is unfairly twisting his proposal.
''There are 7 million disabled Americans who rely on Medicaid, many of them to get out of bed each morning,'' Gore said to Bradley in a testy exchange last week on NBC's ''Meet the Press.'' ''Half of the people with AIDS, and two-thirds of all the seniors in nursing homes, rely on Medicaid. He eliminates it.''
Bradley says Gore has distorted his notion. ''There's an absence of telling the whole story,'' he said on the program.
Bradley aides call Gore hypocritical for attacking a plan the vice president once supported, and that claim resonates with some Medicaid specialists. ''There are details one can worry about, but it seems peculiar to make the issue one of principle, since the principle was part of the Clinton/Gore national health reform,'' said Paul Offner, a Georgetown University professor who ran the Medicaid programs for Ohio and the District of Columbia.
''It's unfortunate that the Gore campaign is criticizing Bradley, because Bradley's plan is similar to what he originally wanted to do years ago,'' John Holahan, a health policy specialist at the Urban Institute, said of Gore. Holahan says either plan could be made to work.
The Medicaid debate is one piece of a broader discussion of health care that has become central to the Democratic primary campaign. In general, Bradley would spend far more money than Gore - as much as $650 billion over 10 years - in an attempt to move toward covering all 44.3 million Americans who have no insurance.
Gore would spend $264 billion on a plan that focuses most intensely on serving the poor and near-poor. He claims to cover as many as 15 million uninsured Americans.
As in Clinton's 1994 proposal, Bradley would eliminate Medicaid and give beneficiaries money to buy insurance in the private market. He would build on the existing Federal Employees Health Benefits Program, which provides insurance to federal employees, using it to enroll Medicaid beneficiaries and educate them on their choices.
Moreover, Bradley would give money to the many poor and near-poor people who do not qualify for Medicaid because they have no children or do not meet other guidelines. ''Medicaid is supposed to cover people who are poor, but 40 percent of the people who are in poverty in this country do not have any health insurance, none,'' Bradley said recently. ''Medicaid doesn't cover them. Under our proposal, they would have health insurance.''
Gore says that he is open to replacing Medicaid with something better, but that Bradley's plan falls short. He has three major criticisms.
First, Gore says, Bradley offers beneficiaries too little money to buy insurance, forcing them to pay part of their premiums from their own pockets. Many would refuse, Gore says, so Bradley would actually take insurance away from many poor people who currently have it.
Bradley would give $1,800 on average to each adult to buy insurance. That is enough to buy coverage from only 12 of the 300 private plans that offer insurance through the federal employees' program, said Kenneth Thorpe, a professor of health policy at Emory University in Atlanta, who is not aligned with either campaign.
Those 12 plans cover only 5 percent of people in the federal program, and none operates in Washington, Los Angeles, New York, or anywhere in New England. If they moved into those regions, Thorpe said, they would have to raise their premiums to adjust for higher costs in those areas.
''In the Bradley plan, there's a high likelihood and almost certainty that a Medicaid beneficiary will have to pay toward the premium of a new health plan,'' said Thorpe, who was a senior Clinton administration health official when the president offered his own plan.
But Bradley's camp says that many states are already moving their Medicaid beneficiaries into private managed care plans - and for less than Bradley's $1,800 per adult. Tennessee pays for $1,189 a year, for example, and California pays $993.
Gore's second criticism is that private plans offer fewer benefits than does Medicaid, which covers transportation to a doctor's office and requires low or no copayments for medication and doctors' visits. Those features are designed to make sure that low-income people stay in the program.
In his 1994 plan, Clinton would have provided those services as free add-ons once Medicaid beneficiaries joined private plans. But Gore says Bradley would not provide them, and that eligible people would leave the program rather than pay for those services out of pocket.
But Tom Higgins, an adviser to the Bradley campaign, said health plans would be forced to require these extra services if they wanted to serve Medicaid beneficiaries, and that competition among the plans would keep the costs down. ''The vice president talks about the Bradley proposal as if it is an experiment,'' Higgins said. ''But under the Clinton-Gore administration, at least 20 states have received waivers to convert their Medicaid programs to do just this.''
The third Gore criticism involves Medicaid payments to nursing homes. After removing all state responsibility for Medicaid, Bradley would hand states full responsibility for paying for low-income people to stay in nursing homes.
Higgins said the shared federal-state responsibility today leads to poor service, but Gore's side says that under law, the federal government could not enforce its quality standards if it did not fund nursing homes. The result would be a deterioration of service at nursing homes, they say.
For his part, Gore would leave Medicaid intact and make 1 million additional children eligible for it and for a related federal-state program. Most important, he would tell parents that if their children are eligible for either health program, then the parents are, as well. Gore believes this will be a powerful incentive for parents to contact state authorities and enroll their families.
But Bradley says Gore's approach errs in keeping Medicaid's burdensome administrative apparatus in place. Moreover, he says Gore would not cover adults without children or families who narrowly miss Medicaid income cutoffs.
Nor would Gore eliminate ''the stigmatization that comes from Medicaid,'' Bradley said recently in a comment that echoed the conclusion of Hillary Rodham Clinton's 1993 task force.
Several independent specialists say that in many ways, the debate is off the point. Both the Gore and Bradley plans could be made to cover millions of additional people.
The Medicaid system is able to handle the new people that Gore would enroll, they say. And at the right price, every low-income American could find private insurance, as Bradley wants. The big question is whether each candidate can cover the additional people he claims for the price he has set, and whether he would add more money to his plan if he fell short of his coverage goals.
''You could screw it up,'' Holahan said of the Bradley plan. ''But good people thinking through it carefully could make it work.''
''It's not that one approach is better. They're different judgments about politics,'' Offner said. After watching Clinton's 1994 proposal collapse, ''Gore is saying the incremental approach works best, while Bradley says we can make big steps.''
