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By Marilyn Werber Serafini, National Journal
© National Journal Group Inc.
Friday, Oct. 26, 2007

Making sure that everyone in the country has health insurance -- universal coverage -- is an increasingly popular goal. Opinion polls clearly show that Democratic voters want it and that Republicans are warming up to the idea.

Members of Congress who hold key positions on health care panels are also drawing closer to consensus on the need to shrink the ranks of uninsured Americans. "More Republicans now believe that the number of uninsured in this country presents problems to the health care system that ought not be countenanced," Rep. Jim McCrery, the ranking Republican on the Ways and Means Committee, told National Journal. "Republicans are getting closer to the Democrats' ideal of a universal system. We don't want a single-payer system, but we're getting closer."

The leading Democratic presidential contenders have eagerly embraced the goal of achieving universal coverage by imposing new requirements on individuals and employers. Republican candidates are taking a more cautious approach, proposing tax incentives to encourage people to buy insurance on their own and pushing for a relaxation of requirements on insurers in hopes of making coverage more affordable. Even former Massachusetts Gov. Mitt Romney, who spearheaded his state's landmark health care reform law, has backed away from mandating universal coverage.

Just last year, Romney worked with his state's Democratic-controlled Legislature to craft a statute that requires all individuals to have insurance and requires most employers to offer insurance or contribute to their workers' coverage. Massachusetts was the first state to take this innovative step, and Romney's leadership inspired other governors to advocate universal -- or close to universal -- coverage in their own states. Democrats and Republicans alike hailed the law as a sign that the country was ready to make bold changes to reduce the number of Americans lacking health insurance, now some 47 million.

Democratic presidential candidates quickly hopped on the universal-coverage wagon, with plans that follow the Romney approach of mandating that everyone get insurance and helping the poor with the cost. Both Hillary Rodham Clinton and John Edwards would require everyone to have health insurance; people could keep the plan they have or choose from a menu of private insurance options along with one public plan choice.

Both Clinton's and Edwards's plans would also expand coverage for low-income people under Medicaid and the State Children's Health Insurance Program, better known as SCHIP. Barack Obama's overall proposal is similar. He would move toward universal coverage by first mandating health insurance for children.

On the Republican side of the 2008 contest, John McCain, Romney, and Rudy Giuliani focus on providing tax incentives to encourage more people to buy health insurance. Earlier this year, President Bush startled both Republicans and Democrats by advocating such an approach as an alternative to expanding SCHIP. He wants to replace the current health insurance tax break for employers with a tax credit to help individuals buy coverage.

Romney, meanwhile, has veered away from his Massachusetts plan and followed fellow GOP presidential hopefuls in emphasizing "access" to insurance. Romney would give states more flexibility in how they use federal funds to reduce the ranks of the uninsured, and he presumes that states would provide help to lower-income people.

Romney is "trying to distance himself from the [Massachusetts] plan a bit, because conservatives have attacked it," says John Goodman, president of the National Center for Policy Analysis, a conservative think tank in Dallas. "He had to compromise to get anything passed. The Legislature was hugely Democratic." Goodman is one of the 10 experts recruited by National Journal to judge the presidential candidates' health proposals.

On the whole, "health is never a big issue in the primaries for Republicans," notes Kenneth E. Thorpe, professor of health policy and management at Emory University's Rollins School of Public Health. "It didn't surprise me that they put out tepid proposals. In the Romney case, he's saying, 'Let the states do it,' which is fine, but there's no money, so it's not going to happen."

National Journal's judges, regardless of their views on the merits of the various candidates' approaches, generally agree that the Democratic plans would do more to reduce the number of uninsured. On this element of their plans, Edwards and Clinton scored higher than Obama, but Obama rated above all of the Republicans.

The judges complained that many elements of the proposals were too vague to properly assess. And those experts who scored the Democratic plans high on reducing the number of uninsured through mandates also noted the enormous costs of those plans. Even though the proposals include subsidies, NJ's experts voiced doubts about how many low-income people would be able to afford insurance.

Robert Reischauer, president of the Urban Institute, expressed frustration with all of the plans, either because of their expense or because of their possible unintended consequences. "The three Democratic plans all lead to substantial increases in coverage. I doubt if they'll get all the way there, even with individual mandates and subsidies, but it's close enough so it wouldn't be a worry. But we would end up spending a lot more money," he said.

"With Republicans, there would be very little change in coverage, and in some sense, if they unleash the market in an unregulated way, they could get less coverage," Reischauer said. "If you don't require people to have insurance, and [if] the options available are high-deductible plans, virtually everyone under 35 will say, 'It's not worth it. The likelihood of getting sick is very low. I'm going to go bare if I have to pay the first $3,000 anyway.' "

Paul Fronstin, a senior research associate at the Employee Benefit Research Institute, contends that millions of low-income people will remain uninsured unless the cost of health insurance comes down significantly. "Substantial tax credits ... have been shown to be ineffective in getting people to buy [insurance]," he said. "Ultimately, we are going on faith that the various approaches will bring down costs in a measurable way to address affordability."

Targeting The Uninsured

Hillary Rodham Clinton proposes universal health coverage and would get there by requiring everyone to have insurance. Individuals could keep their current coverage or choose from a menu of private insurance options, plus one Medicare-style public plan, under a program similar to the federal employees' health program. She would expand eligibility for Medicaid and the State Children's Health Insurance Program. John Edwards proposes to achieve universal health coverage by requiring all people to have health insurance once his market reforms are implemented and insurance is "affordable" -- by 2012, he estimates. He would create regional Health Care Markets -- essentially, purchasing pools -- to allow individuals to group together to buy private insurance, with one plan choice similar to Medicare. The system would be open to those who don't get coverage through an employer or a government program. All plans would include standard benefits, but families and businesses could buy more-generous coverage. Edwards would expand Medicaid and SCHIP to serve all adults under the federal poverty line and all children and parents under 250 percent of the poverty line. Rudy Giuliani would provide tax incentives for people to buy health coverage. He would give states greater freedom with block grants to enroll eligible uninsured individuals. John McCain would provide tax incentives for people to buy health insurance. He would allow people to buy out-of-state insurance. Barack Obama would require parents to buy health insurance for their children. His goal is to reach universal coverage by 2012. He proposes a national health program to allow employers and individuals without access to employer-sponsored health care to buy coverage similar to what is available to federal employees. Obama would expand eligibility for Medicaid and SCHIP. Young people could be included in their parents' plans up to age 25. Mitt Romney proposes boosting "access" to health insurance by granting states more flexibility in how they use existing federal dollars for Medicaid and SCHIP. His goal is to reach universal coverage. He wants states to craft their own health care programs, which he presumes would come with sliding-scale support for lower-income people.