The Politics of Health-Care Reform

With health-care costs rising and 47 million uninsured in the U.S., Presidential candidates talk about reforming the system. Few have detailed proposals

Editor's note: This story is from the first of two series examining how top Presidential candidates are grappling with the major science and technology topics of the day.

Could 2008 be the year health-care reform becomes a decisive election issue? It's possible. Reforming the nation's system for delivering and paying for health care has never been front and center in an election year, and political pollsters often say it won't take center stage until the number of uninsured reaches 25% of the population. The actual number is probably about 15% right now, judging from 2006 Census Bureau data. Still, there are some signs 2008 may defy conventional wisdom.

For one thing, the 15% slice represents about 47 million people. That's a 5% increase over the prior year and the largest increase in four years, even though poverty levels fell and household income rose in that period. It also suggests there are 8.6 million more uninsured than in 2000, another Presidential election year. On top of that, the percentage of people covered by insurance through their jobs fell to 59.7% in 2006, from 60.2% a year earlier, making even those with insurance feel insecure. And health insurance premiums have risen 78% since 2001, four times the rate of wage increases.

Consequently, in the most recent poll by the nonprofit Kaiser Family Foundation, 30% of respondents said health care is one of the top two issues they want to hear Presidential candidates talk about. Only Iraq ranked higher. And talking they are—virtually every Presidential candidate has made some mention of how he or she would cover the uninsured. The Democratic and Republican candidates do tend to take very different approaches, with the GOP contenders embracing free-market solutions while the Democrats want a stronger role for government. But none has managed to duck the issue entirely.

Candidates' Dilemma

What some of them are trying to duck are the details. Health care "could well be the critical issue in this election," says Robert Blendon, professor of health policy and political analysis at Harvard University's School of Public Health. "The dilemma for the candidates is how they can talk about it in a way that will differentiate themselves from one another without getting into specifics that will turn voters off."

There's the sticking point. Although poll after poll shows a majority of Americans would like to reform the inefficient U.S. health-care system (BusinessWeek 9/17/07), there is no broad consensus on a fix. And because the issue is so complex, it is difficult for candidates to convey a detailed position in a way voters will understand—and, more important, not reject.

Their problem: Any effort to effect large-scale change to the current system will be both disruptive and costly for at least some people. "The thing that is critical to understand is that the middle class may be dissatisfied but most of them have employer insurance, so they have something to lose," says Blendon, who talks regularly with candidates about health-care reform. "They are not prepared for a national experiment that will threaten what they have."

Clinton Legacy

Politicians have also taken to heart the lesson of 1993-94, when then-First Lady Hillary Clinton led the last national effort to reform health care. It ended in disaster, amid charges the Clinton Administration was trying to impose socialized medicine on Americans. As a result, candidates now believe the more detailed a health-care reform plan they put forward, the more political problems they will have. This may explain why Senator Clinton (D-N.Y.) herself, the Democratic front-runner, was that last of the major candidates from her party to to issue a detailed health-care proposal, laying our her proposal on Sept. 17.

Clinton's plan is far less complex than the effort she tried to push through with her husband in the prior decade, but it does go further than that of chief rival Sen Barack Obama by mandating that everyone buy insurance. It also takes on the insurers that were instrumental in scuttling that first effort. Under Clinton's new proposal, all Americans would be required to carry insurance, either through their employers, through an expanded version of the insurance available to federal employees, or a new government-run Medicare style plan. There would be tax subsidies and credits to cover the premiums, and no one could be turned down by an insurer for a pre-existing condition or other health issues. "You'll never again have to worry about finding afforable coverage," Clinton said at a campaign stop in Iowa where she unveiled her plan. "If you pay your premiums and follow the rules, your insuranc company will be required to renew at a price you can afford."

On the campaign trail, Clinton is often questioned about health-care reform and her earlier failure. In an interesting twist, she is trying to turn that failure to her advantage. At the recent meeting of the AARP, Clinton admitted she blew it 14 years ago, but says she learned from that experience how to negotiate the Washington process.

Now she says she is both ready and able to take on the insurance and drug companies that lobbied so hard against the 1994 effort. Her strongest statement to date on that point came Sept. 12 at a Democratic candidates' debate sponsored by the online magazine Slate. "I intend to dramatically rein in the influence of the insurance companies, because frankly I think they have worked to the detriment of our economy and of our health-care system," Clinton said.

For Some, a Centerpiece

So far, polls show Clinton leading with the voters on health care, precisely because they see her as the most experienced of the candidates on this issue. That perception has caused considerable grousing from staffers on Barack Obama's campaign. They find it particularly galling because Senator Obama (D-Ill.) has issued a position paper on health care with far more detail than anything Clinton has provided. An Obama adviser was recently quoted in The New Yorker as saying: "I'm sure George Bush learned how not to invade Iraq. Should we then trust him to invade Iran?"

Obama is not alone in spelling out exactly what he has in mind for health care. John Edwards and New Mexico Governor Bill Richardson have both made it a centerpiece of their campaigns in an effort to appeal to a Democratic base that is more concerned about such matters than are Republican voters. As a result, GOP candidates have been far more circumspect: Republican front-runner Rudy Giuliani doesn't have a health-care issue statement on his campaign Web site, and Fred Thompson, who entered the race in early September, has yet to take a position.

Ultimately, though, political consultants say the details of any reform plan may not matter to the electorate as much as the candidate's commitment to make a change—that and the number of uninsured in the Census Bureau report due out next August, two-and-a-half months before the election.

Check out the slide show for a review of the candidates' views on health-care reform.

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