Democrats Can’t Shake the Pack on Health Care

WASHINGTON —  It is a political paradox. Both in the Iowa caucuses and New Hampshire primary, voters ranked health care at the top when asked which issues most concerned them.

But health care has been almost a nonissue in shaping voters’ decisions on which candidates to support, polls in the contests showed.

The results indicate that none of the contenders has found a way to draw clear distinctions for voters among their competing plans -- all of which represent ambitious efforts to provide insurance to many of the nearly 44 million Americans without it.

“All of us have been unsuccessful at developing a differentiated position,” said Ed Reilly, the pollster for Rep. Dick Gephardt of Missouri. Gephardt centered his presidential campaign on a proposal to provide nearly universal health care, but withdrew after a poor finish in Iowa.

The plans from the major Democratic candidates share a common thread -- they would expand coverage mostly by enlarging public programs for the uninsured, especially a state-federal partnership that covers children in working-poor families.

The key distinctions center on diverging approaches for controlling rising health-care costs -- an issue that none of the candidates has spotlighted in the nomination fight.

In the general election, however, health care looms as one of the clearest contrasts between President Bush and the eventual Democratic nominee. The differences are huge between the Democratic proposals and Bush’s plan to expand insurance through tax credits and to control exploding health-care costs mainly through limits on medical malpractice lawsuits.

Nothing has shaped this campaign’s Democratic health-care proposals more than President Clinton’s failed effort to guarantee universal coverage. From the collapse of the Clinton plan -- which helped trigger the Republican takeover of Congress in 1994 -- the Democratic contenders have learned two lessons.

One is to minimize changes for the nearly 85% of Americans who have health insurance -- they would feel few effects from any of the Democratic plans.

The second is to avoid confrontations with business. Clinton’s proposal to require most companies to contribute to coverage for their workers drew staunch resistance from small businesses.

None of the leading Democratic candidates would ask employers who don’t provide insurance to contribute to coverage. Because of this, the plans carry substantial price tags for taxpayers -- a potential vulnerability against Bush.

The proposals are “a budget buster, so it is tricky terrain for them,” said one Republican strategist close to the White House.

Kenneth E. Thorpe, a former Clinton health official, has estimated that the proposals by Sens. John F. Kerry of Massachusetts and Joe Lieberman of Connecticut, former Vermont Gov. Howard Dean and retired Gen. Wesley K. Clark would cover similar numbers of the uninsured at similar cost.

Thorpe, chairman of Emory University’s Health Policy & Management department, said the Clark and Lieberman plans would cover about 33 million of the uninsured, Dean’s about 32 million and Kerry’s a little more than 28 million.

Over the next decade, the cost of the plans would range from about $750 million for Lieberman’s to more than $932 million for Dean’s. That variation is largely because they would phase in at different speeds; when fully implemented, Thorpe projects all of them would cost about $140 billion a year.

The proposal by Sen. John Edwards of North Carolina is less ambitious in reach and cost. Thorpe estimated the plan would cover about 23 million of the uninsured for an annual cost of about $100 billion when fully phased in.

Each Democrat would pay for his plan by repealing part or all of Bush’s tax cuts.

By contrast, Bush’s plan to provide tax credits of as much as $1,000 for individuals and $3,000 for families to purchase insurance would cost $65 billion over the next decade and cover 3 million of the uninsured, Thorpe calculated.

Almost all the Democratic plans call for a significant expansion of the Children’s Health Insurance Program, which provides care for uninsured children in low-income working families.

Dean would make the CHIP program available to all children and young adults under 25 in families with incomes not exceeding $54,000 a year. All other uninsured adults in families with annual incomes of no more than about $33,000 also could be covered by the program.

Although the CHIP program is funded as a state-federal partnership, Dean would have Washington assume the cost of the expanded coverage.

Under Dean’s proposal, uninsured adults not qualifying for the expanded CHIP program would be allowed to buy into an insurance pool modeled on the coverage plan for federal employees. He also would let small-business owners buy into the insurance pool.

Kerry proposes that Washington assume from the states all the cost of insuring the poorest children covered under Medicaid. In return, the states would agree to contribute to the cost of guaranteeing health insurance through CHIP to all children in families earning about $55,000 or less a year and all parents in families with annual incomes of about $37,000 or less.

Like Dean, Kerry would establish an insurance pool modeled on the program for federal employees and provide tax credits for small businesses to buy into it.

Clark would provide coverage for children through Medicaid or CHIP at no cost to families earning about $27,000 a year or less and provide tax subsidies to ensure coverage for children in families with income about $90,000 or less.

Clark also would pay the full cost to provide coverage for adults earning less than about $14,000 a year and offer subsidies more generous than his rivals to fund insurance for uninsured adults earning about $25,000 or less annually.

Edwards would require that all parents provide insurance for their children (an idea Clark adopted). Edwards would provide coverage at no cost to poor families; he would offer tax credits to families in some higher income brackets to help them cover the insurance cost.

Like the others, Edwards would open the CHIP program to adults. But he would offer less generous subsidies than his opponents for working-poor families to obtain insurance.

Lieberman initially would expand eligibility for CHIP, making it available to the same number of children and young adults as Dean, and slightly fewer older workers. But Lieberman, searching for an approach that relies less on government programs, would phase in generous tax credits that lower-income families could use instead to purchase private insurance through a new government-run pool.

Longshot Rep. Dennis J. Kucinich of Ohio has proposed a single-payer plan to cover all Americans under an expanded Medicare program that he would finance with a new 7.7% payroll tax on business. The plan would cost about $600 billion a year.

Two distinctions could still emerge among the Democrats on health care.

Kerry is hoping to more effectively tout his proposal for reducing the rise in insurance premiums by committing the federal government to footing most of the bill for patients whose health-care costs exceed $50,000 annually. The potential political advantage of that idea for Kerry is that it offers a tangible benefit to the roughly 85% of Americans with health insurance.

Meanwhile, Andy Stern, president of the Service Employees International Union, which has endorsed Dean, is urging the candidate to place greater emphasis on his experience as a doctor.

Dean’s background could give him more credibility as someone who could deliver the changes he is promising.