The long-awaited healthcare proposal Hillary Clinton unveiled yesterday is the most high-profile sign of the consensus emerging among the leading Democratic presidential contenders about how to cover 47 million uninsured Americans.
Essentially, their answer is moderation.
No European-style single-payer plan, no new government bureaucracy, and no taking away the health insurance plans of people who like the coverage they already have.
Clinton and her rivals see political danger in the more radical, start-over-from-scratch approach that she tried to push through in 1993 and 1994, and that flopped spectacularly. Instead, they are looking at models that overlay new ideas, like the landmark healthcare law currently being put into practice in Massachusetts, onto the traditional system.
In a speech at a hospital in Des Moines, Clinton said she would require that all families purchase health insurance, and offer them a range of private plans as well as a public option similar to Medicare, which would also continue. Tax credits would ensure that people paid no more than a certain percentage of their income. Large businesses would have to provide their workers with insurance, or else help pay for it.
Her plan would cost the federal government about $110 billion a year, the Clinton campaign said, to be paid for with a combination of savings from healthcare innovations such as electronic records and more preventative care, as well as a rollback of President Bush's tax cuts for the wealthy.
"We can talk all we want about freedom and opportunity, about life, liberty, and the pursuit of happiness, but what does all that mean to a mother or father who can't take a sick child to the doctor?" she asked.
Clinton touted her battle scars from the healthcare fight of the 1990s, an episode her critics say revealed an epic lack of political judgment, by saying she had learned hard lessons and now knows how to get reform passed. She also made numerous gestures to reassure voters that her proposal is not socialized medicine. She even put the word "choices" in the title of the plan.
Still, Republican candidates went after Clinton, accusing her of proposing another big government program. " 'Hillarycare' continues to be bad medicine," said Mitt Romney.
The biggest difference among the top Democrats - Clinton, Barack Obama, and John Edwards - is that Obama would not mandate that individuals purchase insurance.
But despite the similarities, Clinton's Democratic rivals also attacked her yesterday, some acidly accusing her of copying their plans and charging that she is too tied to Washington special interests to be able to get her plan passed into law. Insurance and drug companies have influential lobbyists in Washington, and also are among the biggest donors to campaigns.
"The cost of failure 14 years ago isn't anybody's scars or political fortune, it's the millions of Americans who have now gone without healthcare for more than 14 years, and the millions more still crushed by the costs," John Edwards, a former senator from North Carolina, said in a speech in Illinois. "So I'm glad that, today, the architect of the 1993 plan has another care proposal - and if imitation is the sincerest form of flattery, then I'm flattered. But unless Senator Clinton's willing to acknowledge the truth about our broken government and the cost of healthcare reform, I'm afraid flattery will get us nowhere."
Edwards also said that as president, he would seek to revoke health insurance for members of Congress and all senior political appointees if they don't pass healthcare reform in six months.
Healthcare is a key issue in the presidential campaign; polls show it is a top domestic priority, along with jobs. It is particularly fraught for Clinton because of her earlier reform bid; in a New York Times/CBS News poll in March, 36 percent of Americans said they had confidence in her ability to make the right decisions on healthcare. But 49 percent were uneasy.
Early in Bill Clinton's first term as president, he put his wife in charge of healthcare reform. She and her advisers were accused of running a chaotic process that shut out potential allies in Congress. Their resulting bill, at more than 1,300 pages, fed accusations that the plan would be a massive government expansion. An insurance industry ad campaign, featuring actors playing a middle-class couple named Harry and Louise worrying about what a "billion-dollar bureaucracy" would do for their health coverage, helped kill the plan.
"I've learned that people who are satisfied with their current coverage want assurances that they can keep it," Clinton said yesterday, stressing, "My plan does not create a single new government department, agency, or bureaucracy."
Clinton said the plan would put responsibility on all the players in the healthcare system. Individuals would have to buy insurance because healthy people need to participate to keep costs down for everyone. Insurance companies would be banned from rejecting people who have preexisting health problems or genetic predispositions to illness. Large employers would have to pay into the system, and small businesses would receive tax credits to encourage them to insure their workers.
Gene Sperling, an adviser to the Clinton campaign who worked on the failed proposal in the 1990s, said the plan would result in a net tax cut, because the tax credits to families who need help paying for their insurance would be greater than the increase in taxes for the wealthy.
Clinton's plan is very similar to Edwards's in broad outlines, although Edwards would require small businesses to help pay for healthcare. Obama's plan would not mandate all individuals to buy insurance because, he said, some families simply cannot afford it. He, however, would cover all children. Among the Democratic candidates, only Ohio congressman Dennis Kucinich advocates a government-run national health insurance system.
Republicans have spent much less time talking about healthcare, and most advocate limiting government's role. Romney would give states incentives to expand affordable coverage, a far more limited approach than the one he helped create as governor of Massachusetts. Former New York mayor Rudy Giuliani would use tax breaks to help families pay for insurance.
Clinton contends that there is a much bigger public appetite for healthcare reform today than there was in the 1990s, thanks to the steep rise in costs and the number of uninsured.
But the deck is still stacked against major reform, said Robert D. Reischauer, president of the Urban Institute in Washington and a healthcare specialist. The next president will probably be so tangled up with the Iraq war, the tax code, and Medicare and Medicaid reform that he or she will be unlikely to be able to tackle such a messy issue, he said.
And the cost savings that are supposed to underwrite universal coverage will be fought vigorously by insurers, hospitals, and pharmaceutical companies, he said.
"There's no question that analysts in a seminar at the Kennedy School could figure out how to save $70 to $100 billion a year," said Reischauer, a member of Harvard's governing board. "But does the political system have the fortitude to enact those kinds of proposals?"
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(Clarification: A chart that accompanied a Page One story yesterday about presidential candidates' healthcare proposals incompletely described the position of Barack Obama on one issue. A spokesman said it is Obama's intention to ban all private insurers from rejecting applicants on the basis of preexisting conditions. His plan specifies that public and private plans participating in a "National Health Insurance Exchange" would accept all applicants, but the spokesman said insurers not participating in the exchange would also be banned from discriminating.)