Fourteen years ago, on October 27, 1993, President Clinton and first lady Hillary Rodham Clintonstrode into the Capitol's Statuary Hall to formally present their ambitious health care plan to Congress. Little did the Clintons and their Democratic congressional allies know that in less than a year the plan would become a legislative fiasco and a major factor in their party's stunning defeat in the 1994 midterm elections.
Now, as the 2008 presidential candidates address health care -- which national polls indicate is the top domestic issue after the economy -- neither major political party has forgotten the lessons of that debacle. But the Democrats may have learned more.
Although Democratic front-runner Hillary Clinton and her two closest rivals, Sen. Barack Obama of Illinois and former Sen. John Edwards of North Carolina, have not abandoned government as a tool to reform health care -- their plans include a raft of mandates and programs as well as federal outlays that could top $100 billion annually -- they do not elevate philosophy over pragmatism. Indeed, they have drawn considerable inspiration from an unlikely source, the universal coverage measure signed into law in Massachusetts last year by then-Gov. Mitt Romney, who is seeking the GOP presidential nomination.
"Democratic candidates are going for proposals that have broad resemblance to the Massachusetts plan," says Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan research organization. "Some Republicans will have to change their tactics, if nominated. They are appealing more to the base."
Indeed, it's striking that none of the top-tier Democratic candidates has seized upon the traditional liberal health care solution -- a single-payer, Canadian-style plan.
"There's plenty of room for theory, but this is a practical problem, and people need to put their heads together to solve it, not retreat to their respective corners," says Bruce Reed, president of the Democratic Leadership Council. "Democrats know that lesson quite well," added Reed, who as chief domestic policy adviser in the Clinton White House watched the complex 1993 reform plan go down in flames.
The health care proposals of the 2008 Democratic presidential candidates differ in ways that health care policy experts can parse but that will elude most voters. The candidates have "stalemated each other," Ginsburg says. "They've all shown that health care -- universal coverage -- is a major priority for them. They've all come up with generally the same approach to it."
Edwards was the first to unveil a comprehensive health care plan, and he stressed its universal aspect in hopes of distinguishing himself from the pack. After Clinton put forward a plan widely viewed as equally universal, Edwards tried to raise the stakes by vowing that if he failed to enact universal coverage within six months of taking office, he would seek to cut off government-sponsored insurance coverage for himself, the Cabinet, and members of Congress. That aggressive vow is a deliberate contrast with the conciliatory tone that candidate Clinton has taken toward health care reform -- a sea change from when she led the charge in the early 1990s.
But Clinton, now a senator from New York, is not the only Democrat whose views have evolved. When Edwards ran for president in 2004 he proposed neither universal coverage nor the mandates he now favors. Unlike Edwards and Clinton, Obama would not require all Americans to have some form of health insurance. His mandate would be limited to children, but otherwise largely follows the same contours.
Still Attacking "Hillarycare"
Republicans have never tired of using the 1993 Clinton health care package as a punching bag. And although Hillary Clinton has significantly reworked her proposal, the GOP jabs don't acknowledge any change. In the most recent Republican presidential debate, Sen. John McCain of Arizona predicted that health care "will be one of the defining issues of the campaign because we know there will be 'Hillarycare' resurrected. There will be efforts to have a single-payer, big-government solution by the Democrats." In the same debate, Romney took a swipe at Clinton, saying, "Hillary says the federal government's going to tell you what kind of insurance [to get], and it's all government insurance."
Such lines tend to win applause from Republican audiences, but Rep. Dennis Kucinich of Ohio -- who touts a universal, federally funded "Medicare for all" program -- is the only Democratic candidate embracing a single-payer health plan. Clinton's plan would expand some government insurance programs, but it would also provide tax subsidies to help individuals purchase private insurance and to encourage small businesses to cover their workers. Clinton wants the federal government to require everyone to have health insurance, and she envisions a public program as one option that people could choose, along with private and employer plans.
Even though the GOP's White House hopefuls relish lobbing rhetorical grenades at Clinton on health care, her campaign does not seem worried that they'll inflict much damage. "In a general election, the old Republican arguments, I just don't think they're going to play as well as they think they did in the past," Clinton pollster and strategist Mark Penn declared at a breakfast with reporters earlier this month. "Republicans had their chance -- what have they done? The result is more and more people without health insurance and more and more people worried about whether the system can really work," Penn said. The September unveiling of Clinton's health care plan marked "a very important moment" in her candidacy, he added, showing "both what she's learned and what her vision for change is."
The health plans presented by Clinton, Edwards, and Obama are much more detailed than those of their Republican counterparts. Some observers predict that the eventual Republican nominee will get more specific in the run-up to the general election. But for now, the vagueness of the GOP plans makes it difficult to compare them with one another and with Democratic proposals.
Traditionally, health care hasn't been a driving issue in GOP presidential primary seasons because the party's conservative base tends to care more about candidates' stands on taxes, foreign policy, and social issues such as abortion. The party's 2008 nominee will likely focus somewhat more on health care during the general election campaign to appeal to swing voters.
"It's not really surprising that the Democrats are more specific than Republicans: Health care is an issue that differentiates [Democratic] candidates for their base -- not so for most Republicans," said Gail Wilensky, senior fellow at Project HOPE, who was a health care adviser to President George H.W. Bush.
In the 2004 presidential election, few partisans defected from either party over health care. Of self-described Democrats who named health care as the issue that "mattered most" in deciding how to cast their ballots, 94 percent voted for Democratic nominee John Kerry, according to the National Election Pool exit survey. Similarly, 83 percent of Republicans who cared most about health care voted for George W. Bush.
Independents who ranked health care as their top issue favored Kerry over Bush nearly 3-to-1. Wilensky predicts, "Post-primary discussions will force more specificity from Republicans because the issue [of health care] is too important to too many voters in the general election to tread lightly."
Among the Republican candidates, Romney, who as governor of Massachusetts fathered the first statewide universal coverage health plan, could be in the best position to challenge Clinton on health care, some observers say. As Romney pollster Jan van Lohuizen noted, "If he is in a debate with Hillary Clinton, he can say, 'You tried to solve a problem, and you made a mess of it. I solved the problem, and solved it in a bipartisan way.' "
But although Romney says he is "very proud of what we did in Massachusetts" and holds it up as a model for other states, the health care plan he's running on now is missing the defining features of his Bay State program. Unlike the Massachusetts system, Romney's national plan would not mandate that all individuals have health insurance, would not set up a quasi-governmental entity to help connect large numbers of uninsured individuals with private health plans so that they can purchase insurance at discounted group rates, and would not levy a fee on employers who don't provide health coverage to their workers. (Massachusetts businesses with at least 11 workers must kick in $295 a year for each uncovered employee to help the state subsidize their insurance.)
Romney never favored the assessment on employers and accepted it only under pressure from the Democrats, who overwhelmingly control the Massachusetts Legislature.
Along with fellow Republican contenders McCain and former New York City Mayor Rudy Giuliani, Romney now emphasizes tax and regulatory changes in promoting market-based solutions to the nation's health care problems -- a strategy that will likely appeal to many primary voters. But even GOP operatives say that their party's White House hopefuls have a ways to go in pitching that approach to the broader electorate.
"Conservatives have to come up with a way of selling market-based [health care] policies, but so far we haven't been able to," said Republican pollster Fred Steeper, who worked on George W. Bush's 2000 presidential bid as well as the elder Bush's 1988 and 1992 campaigns.
A GOP operative who didn't want to insult Republican candidates on the record said, "The market-based rhetoric is in itself hollow: You have to translate that into a couple of things like preserving choice, controlling costs, less red tape. They're not doing a good job of articulating that."
The notion that the 2008 Republican nominee will be able to neutralize health care the way that George W. Bush did on another domestic issue -- education -- in his 2000 campaign seems to be a stretch. Eight years ago, Bush's "No Child Left Behind" proposal for increasing accountability in public schools not only cut into Democrats' traditional advantage on the education issue but also helped Bush define himself as a "compassionate conservative" and set himself apart from his own party's members of Congress.
Recalling Bush's success in 2000, Steeper says, "I don't know what a good health plan would be -- coming from the conservative direction -- that would be equally popular and understandable."
Rating the Plans
National Journal asked 10 health care specialists to assess the proposals from the top-tier presidential candidates who have unveiled such plans: Democrats Clinton, Edwards, and Obama, and Republicans Giuliani, McCain, and Romney. (Former Sen. Fred Thompson of Tennessee wasn't included because he has yet to present a plan.) After consulting with those and other health policy experts, we created a system for rating the plans' probable impact on the uninsured, on government spending, on consumer costs, on employer-based insurance, and on the quality of care.
National Journal's judges gave each candidate's plan a series of numerical grades, from 1 to 10, depending on how close they think it would come to achieving a given goal, such as covering the uninsured. A score of 10 indicates that the plan would come extremely close to achieving the goal, and a score of 1 means that it would not come at all close.
The judges, who span the ideological spectrum, are primarily from research organizations, universities, and think tanks. The scores in the articles that follow are averages of the 10 judges' marks for each facet of the candidates' health plans.
Our judges were Robert Blendon, professor of health policy and political analysis at Harvard University's School of Public Health; Stuart Butler, a vice president at the Heritage Foundation, a conservative think tank; Karen Davis, president of the Commonwealth Fund, a private foundation that aims to promote a high-performing health care system; Paul Fronstin, a senior research associate at the Employee Benefit Research Institute, a nonprofit, nonpartisan policy research organization; Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan policy research organization; John Goodman, president of the National Center for Policy Analysis, a conservative think tank based in Dallas; Ed Howard, executive vice president of the Alliance for Health Reform, a nonpartisan health care education organization; Len Nichols, director of the health policy program at the New America Foundation, who worked on health policy at the Office of Management and Budget during the Clinton health care efforts of the early 1990s; Robert Reischauer, former Congressional Budget Office director and now president of the Urban Institute, a left-leaning think tank; and Gail Wilensky, administrator of the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) under President George H.W. Bush and currently a senior fellow at Project HOPE, a health care policy education foundation.
National Journal crafted the survey questions to elicit objective assessments rather than partisan or policy views. Regarding the uninsured, for example, NJ asked the judges how close each proposal would come to providing health insurance for all Americans. We did not want answers that reflected the judges' political leanings or personal views about whether a given plan was the best -- or even a good -- approach.
The judges' scores were fairly consistent. Both liberal and conservative judges gave Clinton and Edwards high marks for aiming to achieve universal health care coverage, for example, even though some judges oppose reaching that goal by mandating that individuals have insurance. And on the question of whether a given proposal would hold down federal spending, conservatives and liberals alike scored the Republicans higher than the Democrats because of the enormous price tags attached to the Democratic plans -- about $100 billion a year.
Starting with coverage for the uninsured, National Journal examines how the presidential candidates' health plans fared when judged on five key criteria.