WASHINGTON Health care could undergo its
biggest revolution in decades under the proposals of
presidential hopefuls trying to fix a system that has left one
in seven Americans without insurance.
No other major industrial democracy has such a large number
of people without health coverage.
Opinion polls have shown health care to be the top domestic
issue for Democrats. At least one survey found that Democrats
ranked it as important as Iraq. Republican voters also are
paying more attention than in past years.
Democratic candidates are proposing universal health
coverage through a mix of public and private plans. Republicans
say they will make insurance cheaper and more accessible
through tax and market changes that may speed up the shift away
from an employer-based system.
"This will be the broadest philosophical debate we've had
about health care in a long time," said Robert Blendon, an
expert on health politics and policy at Harvard's Kennedy
School of Government.
Candidates are churning out health plans that are unusually
detailed for this point in a campaign, although none are likely
to become law without significant evolution, compromise and
input from Congress.
Even that may not be enough. The country has wrestled with
health coverage off and on for decades without consensus.
The two main parties have deep and defining differences.
While the major Democratic candidates differ on details,
they say they are committed to universal coverage. They aren't
proposing a government-run health plan, but they do foresee an
expanded role for Washington in a hybrid public-private system.
"It's heavy-handed," Robert Moffit, a policy analyst at the
conservative Heritage Foundation, said of the approach outlined
by New York Sen. Hillary Clinton and the other Democrats.
"There would be a massive shift in regulatory authority over
health from the states to the federal government."
Republicans don't promise "universal coverage" but
"universal access." Not all the Republicans have yet released
detailed plans but they speak of market reforms and tax breaks
to make insurance more affordable.
Some also advocate "consumer-directed" health care and
tax-favored health savings accounts to stimulate savvier health
spending and "personal responsibility."
Democrats' plans may have bigger price tags but some
experts see the Republican approach as representing a more
dramatic break with the past.
"It gets all confused in the rhetoric but the Republicans
represent a more radical change by moving away from the
employer-based system to tax breaks and the individual
insurance market," Drew Altman, president of the nonpartisan
Kaiser Family Foundation, said in a recent interview. "But I
don't think that thought has crystallized at all for the
An underlying theme to the debate particularly in the
Democratic contest is which candidate would be most likely to
achieve politically challenging reforms, Blendon said.
For Democrats, polls show that Clinton is seen as the most
likely to get the job done. "That's a really big surprise,"
Blendon said ."You could have envisioned the Democratic voter
as saying she lost the last war. Bring in someone new."
Clinton as first lady spearheaded her husband President
Bill Clinton's monumental but ultimately failed attempt to
overhaul U.S. health care in 1993-94.
On the Republican side, former Massachusetts Gov. Mitt
Romney may be the most closely identified with health reform,
because he was the Republican governor of Democratic
Massachusetts when it passed a bipartisan universal coverage
But Romney is not advocating the Massachusetts model, with
its requirements that everyone get covered, for the whole
country, and is not making health his campaign centerpiece.