As voting fast approaches in a hotly competitive presidential primary campaign, the battle in the Democratic field has now focused intensively on healthcare and the question of how “universal” a coverage plan must be.
The dispute reflects a key difference among the party front-runners over how to cover an estimated 47 million people without insurance. Sen. Hillary Rodham Clinton and former Sen. John Edwards are backing requirements that all Americans be covered, and Sen. Barack Obama is supporting such a mandate for children only.
Healthcare has spurred some of the fiercest exchanges among Democrats on the campaign trail, with the Clinton campaign demanding that Obama renounce “misleading” claims and Edwards charging that neither of his chief rivals goes far enough in their reform plans.
Though the specifics of the healthcare proposals are complex, there are compelling reasons why Clinton has chosen to fight on this ground -- and why Obama and Edwards are fully engaged.
The new focus was seized by Clinton’s campaign, which has struggled in recent weeks to respond to attacks from Obama and Edwards that she lacks conviction on key issues. Those attacks seemed to gain traction after an Oct. 30 debate in which she failed to clearly state her stance on granting driver’s licenses to illegal immigrants.
Since then, the New York senator has seen her lead in some states shrink, and at least one new survey shows Obama with a slight lead in Iowa.
In this week’s tussle, Clinton used healthcare as a way to turn the tables on her chief rival. Now she is presenting herself as the candidate with core convictions and bold ideas, and portraying Obama as an opponent of true reform who is being disingenuous with voters.
Clinton’s campaign manager, Patti Solis Doyle, issued a letter demanding that the Illinois senator withdraw a television ad that says his healthcare plan would “cover everyone.” She argued that Obama’s plan would leave about 15 million people uninsured.
“Until the time comes when Sen. Obama has a plan that will cover everyone, you should stop running this false advertisement,” she wrote.
The letter followed a speech earlier this week in which Clinton lashed out directly at Obama, charging that anything less than universal care would be “betraying the Democratic Party’s principles” and that, despite Obama’s contention that his plan offers universal care, it “does not and cannot cover all Americans.”
“When it comes to truth in labeling, it simply flunks the test,” Clinton said.
Obama’s campaign refused to pull its ad, which has been airing off and on in Iowa and New Hampshire since September, and the senator fired back during a speech to Democratic activists here.
“I have put forth a universal healthcare plan that will do more to cut the cost of healthcare than any other proposal in this race,” he said. “Here’s the truth: If you can’t afford health insurance right now, you will when I’m president. Anyone who tells you otherwise is more interested in scoring points than solving problems.”
The debate marks a shift from only a few weeks ago when the Iraq war was the dominant point of contention among the top Democrats. With violence down in Iraq and Democratic campaigns eager to distinguish themselves before the all-important Jan. 3 caucuses in Iowa, healthcare is emerging as the party’s preferred topic.
Moreover, the debate reflects a dramatic shift in the resonance of healthcare as a decisive national issue since 2000, when former Sen. Bill Bradley of New Jersey failed in his quest to win the Democratic nomination by backing universal healthcare coverage. Then-Vice President Al Gore undermined Bradley by denouncing the plan as too costly, but today’s Democratic candidates essentially agree on government-backed healthcare expansions -- as do many voters.
For Clinton, backing a mandate that all Americans have health insurance has proven a popular stand among the party’s liberal base -- lending her credibility with voters who have been frustrated by her more hawkish views on foreign policy and Iraq.
Clinton would require that individuals get healthcare coverage, either through an employer, a government program or their own private plan.
The issue is familiar for Clinton, who famously failed as first lady in the 1990s to revamp the nation’s healthcare system, and now argues that she learned from her mistakes. She said she would seek to work with the same insurance companies that helped defeat her past efforts -- a pledge that has drawn scorn from Edwards, who portrays the industry as an enemy of reform.
Clinton’s plan has its holes. She has not fully spelled out how it would be enforced. Although she and the other candidates would provide some government subsidies, family coverage still costs more than $12,000 a year, and many people could be expected to try to evade the requirement, experts say.
“If you’re not prepared to round up people and arrest them, then [a healthcare mandate] can’t be 100% effective,” said Stuart Butler, a health policy expert with the conservative Heritage Foundation.
Obama’s narrower mandate that requires parents to get coverage for their children has spurred attacks from Clinton and Edwards that he does not truly support “universal” coverage.
But Obama argues that his plan could win broader political support in Congress.
Moreover, his opposition to a mandate could play well with his natural constituency in the Democratic primary: younger voters who tend to be healthier and might resent subsidizing health coverage for older and sicker people.
In the critical early voting states such as New Hampshire, Obama hopes to win support from moderate independents who can vote in either primary and who tend to be less enthusiastic about government interference.
“Sen. Clinton is arguing that the only way to get every American covered is if you force every American to buy healthcare,” Obama told Iowa reporters this week.
He argued that Clinton’s silence on penalties such as fines for those who would not comply with her requirement suggests her criticism of his plan “is more of a political point that she’s trying to make than a real point.”
Obama’s campaign says his requirement that parents get coverage for their children -- as well as another proposal to allow all young adults to stay on their parents’ coverage through age 25 -- could be as effective in the short run as Clinton’s mandate.
Obama says his goal remains to reach universal coverage by 2012, but he does not think it is fair to impose a requirement unless the cost of coverage can be brought down.
“You cannot apply a mandate before the healthcare plans are affordable,” said Austan Goolsbee, a University of Chicago economist who is advising Obama. “It would be completely wrong to do so.”
Strategists believe Obama’s plan might be more saleable in a general election, particularly in the face of expected Republican attacks that a Democratic-backed mandate would result in more spending and government bureaucracy.
But his posture comes at a time when the majority of Democratic voters support the idea of covering all Americans. A recent Los Angeles Times/Bloomberg survey found that about six in 10 Democrats -- and 51% of voters overall -- support requiring coverage for everyone.
Edwards, running third in the polls behind Clinton and Obama, was the first candidate to propose such a requirement. This week, seeking to portray himself as the most aggressive backer of universal coverage, Edwards proposed penalties on those who ignore a mandate; he suggested that violators would face collection agencies or have their wages garnished.
The former North Carolina senator’s campaign is airing a new ad in which he pledges that he would use his powers as president to strip health insurance from members of Congress who do not vote for universal healthcare by July 2009.
Speaking Thursday in Iowa, Edwards criticized Obama for failing to support a universal plan and questioned how Clinton would enforce her mandates, calling universal care a “threshold requirement” for changing the system.
For his part, the Heritage Foundation’s Butler said the candidates’ plans aren’t that different: The leading Democrats, he said, would all expand the role of government and impose new requirements on insurers and employers.
“It’s really an ideological dispute here about who is purest in terms of getting to 100% coverage,” he said.
Experts say it is not clear whether mandating expanded coverage would work.
The requirement to carry auto insurance is often cited as a successful example, but an industry research group estimates that about 14% of motorists are uninsured. That proportion is not much different from the 16% of the population that lacks health insurance.
In Massachusetts, which is pioneering the individual healthcare mandate, officials expect at least 15% of the uninsured to be exempted from the requirement because they can’t afford coverage, even under the state’s generous program.
(BEGIN TEXT OF INFOBOX)
The three leading Democratic presidential contenders all propose expanding healthcare coverage but they differ in the details, particularly when it comes to whether all Americans, or just children, must be covered. All would place responsibility on individuals to make sure they, or their children, have coverage through an employer or a government program, or by buying insurance privately. Here is a look at other key points of their proposals:
Sen. Hillary Rodham Clinton (N.Y.)
* Requires all individuals to have coverage.
* Healthcare providers help enforce the coverage requirement by automatically enrolling uninsured who seek treatment.
* Requires “large employers” to provide coverage or pay into a public program.
* Provides businesses with 25 or fewer employees with tax credits to encourage them to obtain or continue offering coverage.
Sen. Barack Obama (Ill.)
* Requires parents to obtain coverage for their children.
* Schools help enforce requirement by checking coverage when children enroll for classes.
* Requires all employers, except for start-ups or very small businesses, to provide coverage.
* Provides subsidies to help employers lower the cost of premiums for their employees.
Former Sen. John Edwards (N.C.)
* Requires all individuals to obtain coverage by 2012 with exceptions for extreme financial hardship or religious beliefs.
* Enforcement rules would require individuals to show proof of insurance when paying income taxes or seeking treatment.
* Individuals who refuse to participate could see their wages garnished or face penalty payments.
* Requires all employers with five or more workers to provide employee coverage or contribute 6% of payroll toward health insurance.
* Provides tax credits for families buying insurance and creates regional purchasing pools to make coverage more affordable for businesses.
Sources: PricewaterhouseCoopers Health Research Institute; Los Angeles Times reporting.