Voters See Very Different Healthcare Plans from Obama, Clinton, and McCain

In September, when Democratic presidential candidate Hillary Clinton announced her plan for universal healthcare, blue-and-white signs proclaimed the "American Health Choices Plan." The backdrop at the Des Moines hospital where she took the podium was stamped with dozens of minilogos repeating the same slogan. The message was clear to anyone who remembered the missteps of the healthcare reform plan she spearheaded during the Clinton administration: This time, you get to choose.

Some healthcare workers are among those who are pushing for universal health coverage.

(Jennifer Graylock/AP)

Despite candidates' efforts to highlight their plans' special features, so far the debate over healthcare reform hasn't seemed to offer voters much in the way of choice. Through the long primary season, voters have been parsing the details of Senator Clinton's and Sen. Barack Obama's plans. But with more similarities than differences, it's been hard to get too heated about who's got the best ideas to fix the system. Now that Sen. John McCain is the sole Republican candidate, that's about to change. When the Republican proposal gets an airing, voters will be confronted with two starkly different visions for reforming healthcare. Although healthcare remains a top domestic issue, broader economic worries may overtake voters' appetite for major systemic change, shifting the focus to nuts-and-bolts concerns about their own coverage and how to afford it instead. But the candidates are focusing on major reform, and, when referring to healthcare reform, they generally focus on two primary areas: accessibility and affordability. Typically, Democratic plans emphasize ways to get as many people covered as possible, while Republicans stress bringing down costs.

Not since the decisive failure of healthcare reform during the Clinton administration in the early 1990s has there been such intense interest in this issue. Blame the increasing number of uninsured—47 million at last count—and relentlessly rising costs, say analysts. "The middle class is worried about affordability. They see it in rising premiums and in copays," says Len Nichols, director of the health policy program at the New America Foundation. Premiums rose 6.1 percent last year, more than twice the rate of inflation and significantly outstripping the 3.7 percent increase in workers' earnings, according to the Kaiser Family Foundation's 2007 Employer Health Benefits Survey. Since 2001, healthcare costs have increased 78 percent, according to Kaiser. Meanwhile, high healthcare costs make it increasingly difficult for businesses to compete against companies overseas that typically don't offer health benefits, says Nichols. Since 2000, the portion of firms offering health insurance has shrunk from 69 percent to 60 percent.

With the number of people lacking health insurance growing every year, Democrats have rallied around the banner of universal healthcare. Former Democratic presidential candidate John Edwards deserves a nod for this; his comprehensive plan requiring everyone to have healthcare coverage set the bar for the other candidates. The plans of both Clinton and Obama share many of the key elements of Edwards's plan. The groundbreaking 2006 Massachusetts law requiring nearly all residents to have health insurance also deserves credit for helping shape the debate. "The fact that Massachusetts did universal coverage made it sort of hard for a Democratic candidate not to be for it," says Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

Both the Clinton and the Obama plans would build on the current system of employer-sponsored healthcare. Employers would be expected to either offer health insurance or contribute to the cost of covering their employees. Both plans would expand federal SCHIP and Medicaid programs and create a new health plan that's similar to what is offered to federal employees, with subsidies to make it affordable. Insurers would be required to cover everyone, regardless of health.

The plans have their own individual flourishes. Clinton would guarantee that premiums don't exceed a percentage of family income, while Obama would reimburse employers for major medical costs if they agree to plow the savings into reducing employee premiums. But the major difference between the two plans involves requiring people to have health insurance, the "individual mandate," as it's called.