Hillary Rodham Clinton, Barack Obama and John Edwards have been sniping at each other for months over healthcare, but there's one thing the top Democratic presidential candidates agree on: Americans of all ages should have the choice of buying a government-run plan modeled on Medicare.
The idea, which would set up a competition between a new government plan and private insurance programs, has been overshadowed by the political horse race. But it's one of the most far-reaching and controversial proposals for making health insurance more affordable and more widely available.
The government now guarantees access to healthcare only for seniors and the disabled through Medicare and for the poor mainly through Medicaid. Under the proposals being advanced by Clinton, Obama and Edwards, the government would offer coverage for middle-class workers and their families, with benefits comparable to those now provided for federal employees and members of Congress.
Participation in the government plan would be voluntary, but the approach sparks widely differing reactions.
Mark McClellan, the former Medicare administrator in the Bush administration, called it a risky departure from the state-based changes that the Democratic candidates have cited as their models.
"Of all the states that are considering [reforms], none have set up a public plan to compete with private plans," McClellan, now with the Brookings Institution public-policy center, noted. "It could end up being a back door to single-payer," he added, referring to a government-run system such as Canada's.
What McClellan and other critics say they fear is that the government plan could underbid private insurers and, if large numbers of people sign up, it could eventually replace private coverage, including the employer-sponsored plans that now serve most middle-class Americans.
Some also fear that the government program would become a dumping ground for the most seriously ill -- and expensive -- patients as private companies cherry-picked those least likely to file large claims. If that happened, the federal program's cost would soar.
Despite these concerns, other experts say that giving people the option of joining a government plan might make for a sensible experiment.
"It could be a really fair way to test the market, both in terms of people's preferences and to see what kind of plan can be more successful over time," said health economist Marilyn Moon, a Medicare and Social Security trustee during the Clinton administration.
For example, Moon suggested that a government plan could be used to test ideas for reducing waste and improving quality, such as cutting payments for treatments of dubious value and rewarding hospitals and doctors that document improved results in patient care.
"You could allow a government option as a way of setting a standard, as opposed to issuing lots of regulations that would apply to every insurer," she said.
Republican presidential candidates also have healthcare plans, but -- in keeping with conservative principles -- they rely on market forces, economic incentives and the private sector to increase access to medical insurance and to try to rein in costs. None favors creation of a government alternative to private programs.
GOP opposition is not the only political obstacle to the Democratic idea.
The insurance industry, one of the nation's most powerful lobbies, is against it. "It is a move to significantly expand the role of government and move people off private coverage and to public coverage," said Karen Ignagni, president of America's Health Insurance Plans and the industry's top lobbyist in Washington.
Another critic is GOP presidential candidate Mitt Romney, who as governor of Massachusetts signed bipartisan legislation to provide coverage for all state residents -- a model for the Democratic candidates.
"You can call [the government plan] an option, but if you don't put any restrictions on who can enroll, and you give the government leverage in terms of ability to negotiate prices, you create a situation that leads to a government-run system," said Lanhee J. Chen, Romney's domestic-policy advisor.
Clinton, Obama and Edwards dismiss the charge that they are trying to introduce the camel's nose of government-run healthcare under the tent of health reform.
"Hillary never supported a single-payer system, not even in the early 1990s," said Neera Tanden, Clinton's health policy advisor. "She has always supported a plan to build on what we have in our healthcare system." (Only one Democratic candidate, Rep. Dennis J. Kucinich of Ohio, favors switching to a full-blown government-run system.)
"The charge that this is socialized medicine is ridiculous," said Austan Goolsbee, a University of Chicago economist advising Obama. "This would remain one choice among many, and you don't have to pick it. You can pick a private option, or insurance through your employer."
The candidates' plans differ in some important provisions, and certain key details are not yet spelled out. But Clinton, Obama and Edwards follow the same basic framework.
As a starting point, they would create new insurance-purchasing pools through which individuals, families and businesses would have the option of buying coverage from a broad range of commercial insurers -- or the new government plan.
Private insurers who wished to participate in the pools would not be allowed to turn people down because of previous health problems, and the insurers would be limited in how much they could raise premiums to account for a person's age and other factors that can affect health. All of the plans in the pool would have to offer a minimum standard benefit package, which would probably be keyed to the government plan.
Individuals and families eligible for government subsidies through the candidates' health plans would be able to use that assistance to buy either a private plan or the government's.
Businesses would be allowed to participate in the purchasing pools and enroll employees in the government plan. However, in Obama's plan, participation would be limited to small firms and individuals who don't have access to employer coverage.
The question of how a government plan would fare in competition with such well-known brands as Blue Cross Blue Shield, Kaiser Permanente and Humana is a matter of intense speculation among policy experts and people in the healthcare industry. It's generally assumed that the government plan would cost less than many of the private options. But it's not clear whether that would necessarily give it an advantage.
Government coverage "could become the fallback plan for sick people," said health economist Jack Rodgers of the consulting firm PricewaterhouseCoopers. "If you end up with a federal plan that has a lot of sick people in it, is that something that you would want the federal government to subsidize, or would it be doomed?"
Most healthcare costs are incurred by the sickest patients. In any given year, about 10% of the population accounts for more than 60% of healthcare costs -- a phenomenon that partly explains why insurers go to great lengths to avoid issuing policies to people with medical problems.
Edwards' policy director, James Kvaal, said Edwards would insist on regulations to prevent private carriers from dumping their sickest patients into the government's care. "We will stop private insurance companies from competing by weeding out the sickest people," Kvaal said.
But what if those patients -- weary of dealing with private insurers -- sought out the government plan as a haven? Rules for insurers might not protect the government plan in such a situation. Instead, lawmakers might have to wade into the complex business of trying to adjust premiums between the government plan and the private policies.
The candidates acknowledge that their plans are broad brush strokes for now, and important details would have to be decided with Congress. Nonetheless, the consensus among the three means that if a Democrat is elected, a new government insurance plan for the middle class could well be part of the strategy for tackling one of the nation's most worrisome problems.
"Sen. Edwards has heard from a lot of people on both sides," Kvaal said. "Some people feel very strongly that without the profit motive, healthcare could be offered at higher quality and lower cost. Some people feel that private plans are more nimble and innovative. Offering both in competition gives families a choice."