Clinton faces life and death health battle: If Congress says yes to the bill, his presidency will be on the road to recovery - if it says no, he'll be on life support

BOB DOLE, the notoriously crabby Senate minority leader, rose on the floor of the chamber and uttered a single sentence three times: 'America has the best health care system in the world.'

If it was an invitation to abandon the task in hand - crafting a bill to redesign the US health system - few rushed to accept. Some Democrats may wish they had.

It is 11 months since Bill Clinton strode into a joint session of Congress and brandished the 'health security card', which he said would one day be issued to all Americans to guarantee medical care whenever they needed it. Since then his plan, shaped mainly by Hillary Clinton, has been through the crusher of a dozen congressional committees; it has been corroded by ideological opposition from conservatives - Republicans and some Democrats; and it has been mangled and misrepresented in a mammoth lobbying offensive by the pharmaceutical industry and private health insurers.

The versions now feeding into both chambers - for a legislative showdown this week that may decide the fate of the Clinton presidency - are of only passing similarity to the original White House plan. But the President has declared that two - those offered by George Mitchell, the Senate majority leader, and by Richard Gephardt, the majority leader in the House - do meet his bottom- line requirement: that they will lead, one way or another, to universal health care. All that remains, therefore, is for Congress to hear his voice and weld them into a single law.

But the President has the political equivalent of laryngitis. His voice, already weakened by recent bitterly partisan hearings into the Whitewater affair, was thinner than ever after the dramatic rejection by the House late on Thursday of a dollars 33bn ( pounds 21.5bn) crime bill. As well as being popular with voters, it was part of the twin core of the President's legislative agenda, alongside health care.

If Mr Clinton stumbles again, this time on health care, he risks being dismissed as an irretrievably failed president - with more than two years of his term still to run.

Although it is possible that the crime bill, which aimed to swell police forces and toughen sentences for criminals, might be salvaged this week, the effect of its defeat has been profound. It fell in the House - on a procedural matter - because 58 Democrats were willing to defect to the other side, in open defiance of White House appeals for party unity. 'It happened because members of Congress just aren't afraid of Bill Clinton and that's the biggest problem he faces,' concluded William Schneider of the American Enterprise Institute. 'And losing begets losing.'

The humiliation may galvanise the President. On Friday, he tore up his Washington schedule and flew to Minneapolis to use the platform of a police forum to accuse Congress of succumbing to pressure from Republicans and lobby groups, especially the National Rifle Association. 'It's the same old Washington game,' he railed. 'Just stick it to ordinary Americans, because special interests can keep you in Congress forever.'

Meanwhile, almost the entire Clinton cabinet descended on Congress to pressure Democratic waverers on the health- care bill. If this Congress passes a bill enacting universal care, or at least something close to it, it will be responsible arguably for the most important piece of social legislation since the adoption of the civil rights laws in the 1960s. It will have succeeded where Roosevelt, Truman, Nixon, Johnson and Carter failed.

And there is themoral case. Mr Dole's assertion last Tuesday of the world supremacy of the American health system is true - if you are lucky enough to have access to the best of American care. But that is hardly what the debate is about: it is about minimum medical security for the 15 per cent of Americans - 39 million people - estimated to be without any health insurance. As Mr Dole's Democratic colleagues were quick to point out, America's true global distinction is to be the only industrialised country that does not attempt to offer universal care.

But in this town, sentiment and history count for little. What matter are political calculations. Although the public appears sold on the goal of universal care, it is increasingly ambivalent about how to achieve it. Any perception of government control - 'socialised medicine' as Republicans glibly characterise it - fuels wide suspicion.

Thus a provision that was vital to the Clinton model and retained by Mr Gephardt's, to oblige most employers to pay 80 per cent of their workers' health premiums - the so- called employer mandate - has become the main bogey of conservatives and increasingly of the voters. The Mitchell bill is a tightrope compromise that keeps the employer mandate but conceals it. It seeks first to ensure health coverage for 95 per cent of Americans by 2000, through an array of subsidies to the poor, young and unemployed, as well as through market measures including a punitive tax on insurance premiums that overshoot government-determined limits. Only if the 95 per cent is not achieved might a requirement on employers to pay half their workers' premiums be introduced, and only in 2002.

Considering it the best he might get, the President endorsed the Mitchell text. There is no disguising, however, that it is just a distant cousin of the original Clinton version, which would have been more regulatory - setting ceilings, for instance, on insurance premiums and imposing regional co-operatives to buy health insurance en bloc.

Mr Mitchell is in trouble with at least 10 Democrats in the Senate, many of them Southern conservatives, tending towards feebler versions that include neither mandates nor new taxes, and which would leave 25 million still unprotected.

Meanwhile inthe House, the Gephardt bill, which is much more closely related to the Clinton plan, may have an even bleaker future, precisely because of its reliance on the employer mandate. Late last week, the Democratic Speaker, Tom Foley, announced that the start of formal debate in the House, due tomorrow, had been put off indefinitely.

'I just don't know that we've got our act together,' remarked Dan Rostenkowski, the former Ways and Means Committee chairman. A Republican senator, Trent Lott of Mississippi, echoed the remarks of many colleagues by predicting the Gephardt bill was 'history'. He went on: 'And more than likely there is not going to be a Mitchell bill. The people do not want this government takeover.'

The Democrats are skittish because of the imminence of the mid-term elections on 8 November, when a third of all senators and every representative in the House will face the voters. Republicans are equally nervous. They fear being portrayed as visiting gridlock on Washington once again. For both sides, there is the miserable prospect of facing the public with little to show for this session.

Mr Clinton has skirted disaster numerous times before. If the crime bill can be salvaged and the Mitchell bill protected from Republican torpedoes, then perhaps the misery can be turned again to optimism. But as of this weekend, his most cherished ambition - to deliver to Americans the missing piece of the jigsaw of Roosevelt's New Deal - looks to be in awful peril.

(Photograph omitted)