By Christopher Lee
Washington Post Staff Writer
Tuesday, March 6, 2007; A03

Former senator John Edwards (D-N.C.) says providing health coverage to the 47 million Americans who lack it is so important that he is willing to raise taxes to do it.

Sen. Barack Obama (D-Ill.) says he is determined to enact universal health care by the end of his first presidential term.

Sen. Hillary Rodham Clinton (D-N.Y.), no novice on the subject, calls universal coverage "not only a moral and health imperative, but an economic and jobs imperative as well."

Although health care is usually a bigger factor in Democratic primaries than in Republican contests, at least two GOP contenders -- former governors Mitt Romney of Massachusetts and Tommy G. Thompson of Wisconsin -- are expected to use their extensive track records on the issue as campaign selling points, especially if either emerges as the party's nominee.

All of which illuminates the reality that no White House hopeful can be taken seriously in the rapidly evolving 2008 race without confronting what many Americans have long said is one of their biggest concerns: the availability and affordability of health care.

"Every candidate is going to have to have a health-care plan, because it is the number one domestic policy issue on the minds of voters," said Karen Ignagni, president of America's Health Insurance Plans, an industry group whose "Harry and Louise" television ads in the early 1990s helped torpedo the last big push to overhaul health care.

Although fixing health care is back in vogue, some analysts worry that the prescriptions of the presidential candidates miss the heart of the problem. All the talk about creating universal coverage has obscured the fact that most voters already have insurance, some analysts say, and what they are most concerned about is curbing costs.

"They want some more active government effort to change the way the insurance system works, and to put some more pressure on doctors and pharmaceuticals and hospitals to give a better deal to working people," said Robert Blendon, a professor and public opinion expert at the Harvard School of Public Health. "The cost issue is a very important driving issue, and politicians haven't figured out how to touch that nerve yet."

Taking on costs is more difficult politically because it generally involves challenging powerful interests with a financial stake in the current system, including hospitals, doctors, and drug and insurance companies, said John Rother, policy director for AARP, the seniors lobby.

"The heavy lifting from a candidate's point of view is what they would do to control costs," Rother said. "Getting everybody covered is significant, but it doesn't take you right up against the power of the $2 trillion-a-year medical lobby the way that cost containment does. That's what's missing in the debate."

Since 1999, health insurance premiums have risen faster than wages and inflation. U.S. spending on health care, already the highest per person in the world, is expected by 2016 to nearly double, to $4.1 trillion. One in six Americans has no health insurance, and a shrinking share of those who do can get coverage through their jobs, census figures show.

The burden of rising costs on employers has led to calls for major change, even from some business groups that opposed earlier efforts to revamp the system. Pressure is also bubbling up from states, most notably California, Massachusetts and a few others that have begun, or are considering, statewide experiments to make health insurance affordable for everyone, through state subsidies and new fees on businesses if necessary.

"We're at the beginning of the next great debate about health reform," said Drew Altman, president of the Henry J. Kaiser Family Foundation, a nonpartisan source of health-care information. "This is an issue which was very much on the minds of the American people as an economic worry for quite some time, but was just nowhere as a national political priority even six months ago. Now it's front and center again, and the words 'universal coverage' are back at the center of the debate."

Indeed, analysts say national politicians are approaching the subject with a zeal not seen since the Clinton administration's health plan collapsed in 1994, amid concerns that it would give big government too much control over the health-care system.

Edwards has so far staked out the most detailed position. His plan would require employers to provide health coverage for workers or pay a portion of their payroll into a fund that would help individuals buy private insurance through new regional health-care purchasing pools. He would also expand Medicaid and the state-federal Children's Health Insurance Program, and would provide tax credits to help make insurance more affordable for lower-income families.

Most of the $90 billion to $120 billion annual cost could be paid for by eliminating President Bush's tax cuts for households earning more than $200,000 and by increasing Internal Revenue Service efforts to collect unpaid capital gains taxes, Edwards has said.

"I want to start putting universal health care in place as soon as I am sworn into office in January of 2009, which is what America needs," he said at a Feb. 22 candidate forum in Carson City, Nev. "We can't wait."

His campaign sent a mailing yesterday touting the plan to more than 70,000 Iowa households, the first such large-scale voter contact effort by a Democratic presidential candidate.

The 12-page booklet notes that 265,000 Iowans have no health coverage and argues that only Edwards has a plan "that will cover all of them and lower healthcare costs for everyone." It does not mention the program's cost.

Obama has not released a detailed plan, but in announcing his candidacy last month he said he would deliver universal health care by 2012. "Let's be the generation that finally tackles our health-care crisis," he said. "We can control costs by focusing on prevention, by providing better treatment to the chronically ill, and using technology to cut the bureaucracy."

Clinton said last month that she wants universal health-care coverage by the end of her second term, but she has not offered a plan to achieve it. She has said that she "learned from experience" that no comprehensive proposal will work unless employers, government and labor organizations support it, and that simply throwing money at the problem will not solve it.

"I am looking for answers that will not have us spend more money," Clinton said while campaigning in New Hampshire last month. "I am convinced we can do that."

Rep. Dennis J. Kucinich (D-Ohio) has proposed expanding Medicare to cover everyone, a plan he says would eliminate any role for for-profit insurance companies. Their certain opposition would be a major political obstacle.

Polls by Gallup and other organizations routinely show that Democrats are more likely than Republicans to rate health care as an extremely important issue for Congress and the president. Still, some Republican presidential hopefuls have considerable bona fides on the issue. In 2006, Romney signed legislation requiring that all Massachusetts residents have health insurance by July of this year. Thompson served as President Bush's health and human services secretary at a time when the administration successfully sought to create a drug benefit under Medicare.

Whoever wins the presidency will have trouble converting voters' desire for change into politically viable legislation, analysts say. There is broad agreement on health-care problems, but a consensus on how to fix them remains elusive -- a reality Bush encountered when his recent proposal to overhaul the tax treatment of health insurance fell flat in the Democratic Congress.

"One thing that history really shows us is that the enthusiasm at the beginning of these debates often wanes when you get to the details at the end," said Altman, the Kaiser president.

Washingtonpost.com staff writer Chris Cillizza contributed to this report.