Insurers fight to write off Hillary's health plan: America's First Lady has been rattled by some well-financed attacks on her health care reforms, writes Patrick Cockburn in Washington

HILLARY CLINTON is usually cool and regal as she explains how the Clinton presidency will provide universal health care, but this week there was a touch of desperation in her tone. She accused the insurance industry of telling 'great lies' and bringing the American health system to the brink of bankruptcy.

She said the insurers had driven up medical costs and refused coverage to sick people. 'Now they have the gall to run television ads that there is a better way,' she said. 'It is time to say to the insurance industry, 'Enough is enough. We want our health care system back'.'

Her immediate target was a television advert that shows a homely white middle-class husband and wife looking mournful as they examine the details of the Clinton health plan. Paid for by the Home Insurance Association of America it concludes with the wife sighing: 'There must be a better way.'

The sharper rhetoric from Mrs Clinton reflects the sense in the White House that the popularity of its health care package is ebbing. At the weekend a poll showed Americans split at 45 per cent for and against the plan, with support dropping from the 59 per cent approval it enjoyed when President Clinton presented it to Congress in September.

More depressing for the White House, only 23 per cent said the plan should be passed as it is now and almost half wanted Congress to make changes. Some 56 per cent thought costs would go up and one-third expected quality to decline.

The fall-off in support comes before opponents have really begun to fight. The dollars 6.5m ( pounds 4.4m) the insurers spent on the ads Mrs Clinton objected to is nothing compared to the money that will be spent over the next year. The problem for the Clintons is that their plan and its presentation have always had inherent weaknesses. Many stem from President Clinton's tendency to avoid confrontation until the last possible moment. The first draft appeared to be directed at reassuring doctors, patients, hospitals and insurance companies that nobody would lose out.

The result is that the administration has a plan that is 1,342 pages and 240,000 words long and is very difficult to explain. This means that as Mr and Mrs Clinton stump the country they have no simple slogan around which to rally support. From an early stage the Clintons also 'signalled flexibility'. This may be a useful tactic to reduce pressure, but it is also dangerous because it advertises weakness. Russell Baker, the columnist, says: 'In Washington the signal is most likely to be read as meaning, 'I'm just a pussycat - kick me'.'

It is not that Mrs Clinton's pillorying of the insurance industry is unjustified. In her speech this week she said insurance companies 'like being able to exclude people from coverage because the more they can exclude, the more money they can make'. But, if true, this strikes at the heart of the basic premise of the Clinton health plan, which seeks to preserve the private insurance industry as if it were an endangered species.

Perhaps Mr Clinton felt he had no choice. He was elected with only 43 per cent of the vote. The country may want change, but nothing too radical. As a result, his plan purports to transform the one-seventh of the American economy devoted to health care without abolishing anything. Although the administrative costs of the US health system are already three times as high as in Britain, Mr Clinton will actually add to the bureaucracy by making everybody join a Health Maintenance Organisation. In theory, HMOs will use their massive buying power to force down medical costs, even though their record is dubious where they already exist. In Western Europe and Canada governments control health costs by the more direct method of setting the prices to be paid to doctors and hospitals. Mr Clinton, by way of contrast, will stop controlling prices for many old and poor patients.

It is easy to underestimate the difficulties facing the Clintons. Health reform will affect 600,000 doctors, paid an average of dollars 170,000 a year. The insurance industry lobby is probably the most powerful in Washington. The White House strategy has been to buy off and divide the opposition. Under the plan big insurers will get 37 million new customers who are uninsured. Doctors may also see their incomes go up by about 15 per cent to dollars 196,000.

The organisation that funded the advertisements to which Mrs Clinton so objected represents the smaller insurance companies. The White House has been trying to divide them from the larger companies, which may benefit from reform. The problem is that the American public increasingly suspect that it is they who will be left with a much increased bill.