Universal Health Care Gets Boost
Democratic Rivals Push New Plans

By Amy Goldstein and Dan Balz
Washington Post Staff Writers
Monday, May 26, 2003; Page A01

Democratic presidential candidates have resurrected universal health care -- an issue that produced one of the low points of Bill Clinton's presidency -- in a calculated gamble that the voters are ready for a new debate over providing access to health care coverage to all Americans.

Four Democratic candidates have come forward with proposals to bring most of the 41 million Americans without insurance into the health care system, and others are in the process of refining theirs. Although the plans differ in some significant ways, they have two things in common: All are big and ambitious, and are far costlier than anything that has been proposed since Clinton.

The proposals on the table represent an abandonment of the incremental steps favored by Democrats -- and Republicans -- since the Clinton health plan debacle of 1994, but they also demonstrate the lessons learned from that defeat. With one exception, the Democratic plans seek to expand coverage by building on the existing system rather than creating a new one.

That does not lessen the political risk, however. Democrats hope they will be rewarded by being bold, but adopting that posture comes at a price. To finance their plans, the Democrats must get rid of most or all of President Bush's tax cuts, an action that plays well with Democratic activists but may be far less popular among swing voters.

By proposing to spend so much on health care, the Democrats will find it more difficult to attack Bush for blowing the budget surplus during his first 21/2 years in office. Under a plan proposed by Rep. Richard A. Gephardt (D-Mo.), the deficits would be as large or larger than Bush's. While talking about returning to fiscal discipline, none of the Democrats has offered a credible plan for reducing the deficit.

Health care has surged into the forefront of the Democratic debate for practical and political reasons, according to party strategists and public opinion analysts.

"We are spending a ton of dough on health care and it's a major public policy problem," said Bill McInturff, a Republican pollster. "You can try at the state level to adjust and modify, Congress can try smaller bills, but there is a 'health care system,' it is in trouble and it requires presidential leadership to try and fix it."

Many Americans are wary of wholesale changes in health care coverage, and health ranks below jobs, the economy and terrorism as a priority. But the weak economy has prompted new worries about the cost of care and the availability of insurance. Nowhere is the support for big changes stronger than among voters who participate in Democratic presidential primaries.

"This is the equivalent of big tax cuts in Republican primaries," said Robert J. Blendon of the Harvard School of Public Health. "I think the candidates made a decision they were not going to worry about the general election. . . . That is the problem with hard-fought primaries. . . . It forces you to play to your base."

Candidate competition drives the debate. Former Vermont governor Howard Dean talked for months about making universal care a centerpiece of his candidacy, but Gephardt moved first to offer a comprehensive plan. Dean offered his plan earlier this month, three days before Sen. John F. Kerry (D-Mass.) announced his proposal; he denied that the timing had anything to do with Kerry's scheduled speech.

The candidates feel pressure to address health care from powerful interests within the party as well. At the airport in Des Moines, nurse Marietta Yoder, stethoscope around her neck, stares out at arriving passengers from a poster that is impossible to miss. "Running for President?" the poster asks. "Health Care better be your priority."

The poster is the handiwork of the Service Employees International Union (SEIU), the largest health care workers' union in the nation. Union President Andrew Stern has told the Democratic candidates that a prerequisite to the SEIU's support will be having a comprehensive plan for insuring all Americans, the means to pay for it and evidence that it will work.

"Our members take care of people, live the problems of the health care system in a way that many other people just periodically see it," Stern said. "Every bargaining that we've had, from janitors to workers to nursing home workers, is about maintaining health care, not about significantly raising wages."

Stuart M. Butler, vice president for domestic and economic policy studies at the Heritage Foundation, said the health proposals enable Democratic candidates to highlight their opposition to the tax cuts Bush has championed. Gephardt, Kerry and Dean have said they would pay for their proposals by eliminating all or part of the tax measures Bush has pushed through Congress.

The Democrats' health plans "[look] at the Bush tax package in the future somewhat as people looked at the surplus or the 'peace dividend' during the Cold War -- that there is a pot of money out there," Butler said.

The proposals from Kerry, Dean and -- most of all -- Gephardt are ambitious and expensive. Gephardt's would cost about $214 billion in its first year of full implementation. Analysts who have vetted the Gephardt and Kerry plans predict they would provide coverage to perhaps 27 million to 31 million of the 41 million Americans who are uninsured. Rep. Dennis J. Kucinich (Ohio), another Democratic contender, has called for the abolition of private health insurance companies in favor of a government-financed system of health care for all Americans.

In producing plans of such cost and scope, Harvard's Blendon said, the candidates appear to have concluded that prescription drug benefits for elderly patients on Medicare -- a promise that was a staple for Democrats and Republicans during last year's midterm elections -- was not a broad enough health care agenda to win over voters.

All of the proposals contain provisions to appeal to three groups: those who lack medical insurance, insured people whose health care costs are escalating and retirees. The candidates also say they will address the issue of prescription drugs for seniors -- adding even more cost to their health proposals.

The plans are similar, too, in that they are built on the existing health insurance system. To various degrees, each proposal would expand employer-based coverage for working people, government programs for the poor and private insurance for people who could afford coverage but cannot get it through their jobs.

Kerry and Dean, in particular, "seem to sort of take the field as they find it and use a mixture of public and private stuff to get the most people covered they can," said Edward F. Howard, executive vice president of the Alliance for Health Reform. "This is an unpretentious, let's-do-what-we-can kind of approach."

Gephardt would require all employers to provide health insurance for workers and offer as an incentive tax credits valued at 60 percent of the cost of that care. Even employers who already provide insurance would qualify for the tax credits, which is the main reason his plan is the costliest. His plan would expand such public programs as the State Children's Health Insurance Program (SCHIP) and provide incentives to fill other gaps in coverage.

Dean and Kerry would make smaller changes in the employer-based system, while calling for larger expansions in SCHIP. Both borrow the popular insurance model used for federal workers to try to make coverage easier to afford for people who work in small companies or now buy expensive individual insurance policies.

With an eye toward the clout of the American Federation of State, County and Municipal Employees union, the candidates also include financial sweeteners for hard-pressed state and local governments, with Gephardt's by far the biggest.

Kerry is the only Democrat to make cost containment a central element of his plan, although the mechanism likely would have more effect on the cost of private insurance premiums than on rising medical costs themselves.

Health policy specialists predicted that Gephardt's plan, with its bigger price tag and requirement for employers to cover their workers, would stand out in the campaign debates. But many of the differences among the plans are "way too complex" for most voters to grasp, Blendon said.

"I don't see how you can sit in a diner in New Hampshire and explain what they would do," he said. Instead, he said, the plans are a kind of political inoculation for the Democratic field. Voters "will look at these and say, 'Hey, these are people who are going to do something significant about health care. . . .' They won't understand the content," Blendon said.

For now, Democrats are engaged in an internal debate, but party strategists see health care as a winning issue against Bush. Republicans counter that this administration has spent more time addressing aspects of health care than previous GOP administrations, but say the Democrats' moves will put pressure on the White House.

"There is a lot of action in this administration with regard to health care," McInturff said. "Every time the Democrats have engaged in this issue, it has required us to disqualify their own plan but also be more cohesive in explaining how to address the same problem."