DR. CLINTON SCRUBS UP

By John F. Dickerson/Washington

You may remember the commercials: Louise sat at her kitchen table, a mass of paper spread out before her. At her side, brow furrowed, sat husband Harry. "Having choices we don't like is no choice at all," she fretted. That was 1994, and the enemy was Bill Clinton and his 1,364-page plan to fix the health-care system. Three years after the death of that plan, things have changed so much that today Clinton could run the ad to make his own point. That's because there's a new bogeyman: managed care. "Clinton's bureaucrats aren't any different than managed-care-company bureaucrats," says Republican Representative Charlie Norwood of Georgia.

Welcome to the next health-care debate. This time it's not about Washington changing the system but about keeping the free market from changing it too quickly. And it's being waged on behalf not of the 41 million without insurance but of the 70 million who have enrolled in health-maintenance organizations. Which is why the President has a better chance of winning this time. The patient "bill of rights" Clinton announced two weeks ago is supported by the American Medical Association, which opposed him last time; 91 Republicans back a bill that resembles Clinton's. What hasn't changed is that hard-liners in both parties think the issue can carry them to success in the 1998 congressional elections. Be prepared for charges that the President is trying to socialize medicine or that the G.O.P. wants to toss sick children into the snow, all of it whipped up by the lobbyists and pollsters that dove into the health-care melee the last time.

America rejected Bill and Hillary's prescription for change in 1993 partly because it threatened their comfortable care in the hands of fee-for-service doctors. But since 1993, the number of people who have been nudged into HMOs has increased 50%, to 67.5 million. And as participation rates have climbed, so have complaints, many of which sound like the horrors that would supposedly have taken place under the Clinton plan: rationing of procedures, a narrower choice of doctors. Fueling the backlash has been a spate of front-page stories about plans that will pay for cataract surgery in only one eye or that keep doctors from discussing expensive types of care. In a recent nationwide poll by the Kaiser Family Foundation, an independent health-care philanthropy, 55% of those in managed care said they worry that their health plan is concerned more about saving money than providing the best care. That negative feeling isn't helped by the premium increases of 5% to 10% that some patients discovered this year when they tore open their HMO enrollment packets.

Since the failure of his first effort, Clinton has trod carefully, offering small but politically popular programs like coverage for uninsured children and a mandatory minimum hospital stay for childbirth. But the bill of rights for managed care is a far more comprehensive set of reforms. It would allow patients to go to the nearest hospital in an emergency, guarantee them access to specialists, provide detailed information about quality of care, and create a system for appealing denials of treatment. Republican House majority leader Dick Armey immediately called the plan "a giant leap toward government-run health care." And other powerful Republicans, like Senate majority leader Trent Lott, argued that it will increase the costs of benefits and thus compel employers to cut back the number of employees they cover. So the top G.O.P. gladiators, at least, are bracing for a fight. "The message we are getting from the House and Senate leadership is that we are in a war," says a memo from the Health Insurance Association of America, the Harry and Louise people.

It is a war many Republicans relish. Clinton's health-care debacle helped them take control of Congress in 1994. The Kaiser poll found that 40% of Americans oppose government tinkering with health care if it means it will cost more. The fear of federal mandates has galvanized the powerful National Federation of Independent Business, Chamber of Commerce and Business Roundtable, which have teamed with managed-care associations to knock down Clinton's plan. It's getting nasty already: behind the scenes, managed-care groups have circulated negative information about the President's commission members who helped draw up his bill of rights. The groups are also letting Republican candidates know that support for federal regulation will cost them in donations.

Even with all that help, the G.O.P. leadership may not have much support from their troops. "I want Republicans to get credit for protecting patients," says Georgia's Norwood, a former dentist, echoing the fears of Republicans who recall how well Clinton used Medicare cuts against them in 1996. With some in the G.O.P. backing the President, there's a good chance a health-care bill will pass next year. And maybe Harry and Louise will be trotted out again, this time on Clinton's side.