Health care visions

<p>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.</p><p> But health care has been almost a nonissue in shaping voters' decisions on which candidates to support, polls in the contests showed.</p><p> The results indicate that none of the Democratic 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.</p><p> "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.</p><p> The plans from the major remaining 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.</p><p> 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.</p><p> 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.</p><h3>Learning from Clinton</h3> <p>Nothing has shaped this campaign's Democratic health care proposals more than the failure of President Clinton's effort to guarantee universal coverage a decade ago. From the collapse of the Clinton plan - which helped trigger the Republican takeover of Congress in 1994 - the Democratic contenders have learned two lessons.</p><p> One is to minimize changes for the nearly 85 percent 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 provoked staunch resistance from small businesses.</p><p> None of the leading Democratic candidates would ask employers who don't provide insurance to contribute to coverage. But as a result, the plans carry substantial price tags for taxpayers - a potential vulnerability against Bush.</p><p> The proposals are "a budget buster, so it is tricky terrain for them,'' said one Republican strategist close to the White House.</p><h3>Costs, coverage</h3> <p>Kenneth E. Thorpe, a former Clinton health official, has estimated that the proposals by Sens. John 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 a similar cost.</p><p> According to Thorpe, a professor at Emory University in Atlanta, the Clark and Lieberman plans would cover about 33 million of the uninsured, Dean's about 32 million and Kerry's just over 28 million.</p><p> Over the next decade, the cost of the plans would range from around $750 million for Lieberman's to over $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 around $140 billion a year.</p><p> The proposal by Sen. John Edwards of North Carolina is less ambitious in reach and cost. Thorpe estimated the plan would cover around 23 million of the uninsured for an annual cost of around $100 billion when fully phased in.</p><p> Each Democrat would pay for his plan by repealing part or all of Bush's tax cuts.</p><p> By contrast, Bush's plan to provide tax credits of up to $1,000 for individuals and $3,000 for families to purchase insurance would cost only $65 billion over the next decade and cover just 3 million of the uninsured, Thorpe calculated.</p><h3>Boosting CHIPs</h3> <p>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.</p><p> Dean would make the CHIPs program available to all children and young adults under 25 years of age in families with incomes up to about $54,000 a year. All other uninsured adults in families with annual incomes up to about $33,000 also could be covered by the program.</p><p> Though the CHIPs program is funded as a state-federal partnership, Dean would have Washington assume the cost of the expanded coverage.</p><p> Under Dean's proposal, uninsured adults not qualifying for the expanded CHIPs 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 new insurance pool.</p><p> Kerry proposes that Washington assume from the states all the cost of insuring the very poorest children who receive coverage under Medicaid. In return, the states would agree to contribute to the cost of guaranteeing health insurance through CHIPs to all children in families earning up to about $55,000 a year and all parents in families with annual incomes of about $37,000 or less.</p><p> 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.</p><p> Clark would provide coverage through Medicaid or CHIPs at no cost </p><p>to children in families earning up to around $27,000 a year and provide tax subsidies to ensure coverage for children in families with income up to around $90,000.</p><p> Clark also would pay the full cost to provide coverage for adults earning less than around $14,000 a year and offer subsidies more generous than his rivals to fund insurance for uninsured adults earning up to about $25,000 annually.</p><p> Edwards would require that all parents provide insurance for their children (an idea Clark adopted).</p><p> 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.</p><p> Like the others, Edwards would open the CHIPs program to adults. But he would offer less generous subsidies than his opponents for working-poor families to obtain insurance.</p><p> Lieberman initially would expand eligibility for CHIPs, 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.</p><p> Long shot Rep. Dennis 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 percent payroll tax on business. The proposal would cost about $600 billion a year.</p><h3>Other factors</h3> <p>Two distinctions could still emerge among the Democrats on health care.</p><p> 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.</p><p> The potential political advantage of that idea for Kerry is that it offers a tangible benefit to the roughly 85 percent of Americans with health insurance.</p><p> 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.</p><p> Dean's background could give him more credibility as someone who could deliver the health care changes he is promising.</p>