"I'M Having Nightmares"

By Michael Duffy, Dick Thompson and Ira Magaziner.

In a rare interview, White House health-care adviser Ira Magaziner met with TIME correspondents Michael Duffy and Dick Thompson for an hour last week to discuss his proposals. Some excerpts:

Q. What will be most different about life in America if Bill Clinton's program is enacted?

A. There's going to be much greater security. Regardless of whether Americans change jobs or lose their jobs or move to another state, they are guaranteed health insurance. That is the biggest difference.

Q. Are Americans going to have to pay more for this security?

A. It depends. People who are not now insured, and the companies they work for, are going to pay a lot more. That's a matter of equity.

Q. How quickly will the uninsured be covered?

A. We haven't really made that decision. If you say to a company you've got to go from zero to ((full coverage)) overnight, you're going to drive a lot of companies out of business. You can't do this overnight, even if you had all the money in the world. The fundamental part of this reform that is often overlooked is that in 10 years from now almost no one is going to remember what you did up front to pay for this. What they're going to remember is that we expanded access to doctors, improved the quality of care, increased competition and so on -- those are really the guts of what is going to make a difference on this long term.

Q. Will every American be going to an HMO?

A. Our job is not to determine who's going to win, whether it's an HMO, a fee- for-service network or whatever. It's just to set a groundwork for who's going to compete and provide choice to all consumers. A lot of people think HMOs are going to win out, but I think Americans like a fee-for-service ((option)).

Q. Can doctors work outside the alliance?

A. If doctors want to be out on their own, they can't be paid through the insurance network. If doctors in Beverly Hills want to get together and do whatever they do, that's fine as long as taxpayers don't pay for it. Even in Sweden, where you have a completely government-run system, private people go to private doctors. You're not going to stop that, and you shouldn't.

Q. Will there be price controls?

A. What we're moving to is a budgeted system, not controls. With controls, you're trying to regulate every transaction, which means you have to set up an enormous regulatory structure, and it's a nightmare for the providers. But with a budgeted system, you give providers a fixed amount of money. You figure out how you want to handle things.

Q. How can you cap what Americans need to spend on health care?

A. You can. Most other countries have proved that you can.

Q. What about short-term price controls on drugs, providers and insurers?

A. You may need to put in some regulation in the short term to make sure the insurance market doesn't go haywire.

Q. How do you feel about the process so far?

A. Every day and every night, I'm having nightmares that something will go wrong. It's a big responsibility. But if we can get comprehensive health-care reform that's really decent, you'll feel like you've really contributed something.