The Politics of Healthcare

Clinton unveils version 2.0 of her universal-coverage plan.

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Senator Clinton has added her blueprint to the mix.

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This election season, a presidential candidate stumping without a healthcare reform proposal would be like a doctor performing surgery without latex gloves. Unthinkable. One by one, the candidates have offered up their plans to address voters' top domestic concern. The latest, unveiled last week: Democratic front-runner Hillary Clinton's long-awaited proposal to guarantee every American insurance coverage. What remains to be seen is whether voters are worried enough about their access to affordable healthcare that the proposed reforms become a key issue at the ballot box.

Americans are certainly worried. Healthcare ranks second only to the war in Iraq among issues they want to hear the candidates talk about, according to the Kaiser Family Foundation's most recent tracking poll, conducted in early August. Republican voters care somewhat less than Democrats do—but that they now rank healthcare No. 2 may be telling, says Kaiser President and CEO Drew Altman. "This is traditionally not an issue that's in the Karl Rove playbook," he says. "Now there's some evidence it's more salient for Republicans."

Biggest worry. Maybe that's because the problem keeps getting worse. A Gallup Poll in July found that healthcare costs are now the biggest financial worry families face, ahead of low wages or even the cost of owning a home. "A lot of the economic insecurity that people are feeling now is tied directly to their concerns about healthcare," says public opinion pollster John Zogby, president and CEO of Zogby International. Little wonder: A typical family pays nearly $3,300 a year out of pocket in premiums for employer-sponsored health insurance; with a record 47 million now uninsured, it's clear that many can't afford it.

Enter the presidential candidates with their solutions. The two parties couldn't be further apart on how they'll tackle the problem. Republican candidates generally advocate tax incentives and market reforms to encourage—but not require—people to buy coverage. Former New York City Mayor Rudy Giuliani, for example, has proposed tax breaks for people who buy private insurance policies.

The three leading Democratic candidates—Senators Clinton and Barack Obama and former senator John Edwards—take a different tack. Their plans, similar in many particulars, would mandate insurance coverage and guarantee that people with health problems would not be turned down. Those who couldn't afford the premiums would be helped to meet the cost. (Appropriately, all three support a $35 billion expansion of the Children's Health Insurance Program, set to expire at the end of September, so that more low-income kids are covered. Currently, the program provides subsidized health insurance to roughly 6.6 million children. Just before Congress reached accord on expanding the program late last week, President Bush firmly reiterated his veto plans.)

More moderate fix. After her attempt as first lady to overhaul the system by setting up regional health-insurance alliances failed miserably—with an assist by TV ads featuring the famously confused Harry and Louise—Clinton this time is proposing a more moderate fix. To critics who would dismiss her current plan as "Hillarycare" redux, think again, experts say. The promise of secure, affordable coverage, regardless of health problems, resonates with increasingly anxious voters. The American people aren't interested in healthcare tax breaks, says Bob Laszewski, a Washington health policy analyst. "They're scared," he says. "You'll get hooted out of the room if you talk about health savings accounts."

Many health policy experts believe that universal coverage is an impossible goal without an individual mandate that people buy insurance. (The three major Democratic plans all contain mandates, though Obama's is limited to children.) Voters have embraced this idea: A Kaiser Family Foundation poll conducted last November found that 63 percent were in favor. "It's amazing how far this new idea has spread, given that we don't have any experience with it except in Massachusetts," says Robert Blendon, a professor of health policy and political analysis at Harvard University. Last year, Massachusetts became the first state to require its residents to have health insurance or face penalties. It's a sign, perhaps, that voters are less interested in the fine print of each proposal than in whether the future president is committed to—and capable of—accomplishing real change.