“I want to be a President who again sets goals for our country,” Hillary Clinton told a ballroom full of supporters at the midtown Hilton on Monday morning. “Here at home, I want to set the goal of universal health-care coverage.”
The fact that Mrs. Clinton puts health care at the very top of her eventual to-do list—more than a dozen years after her disastrous first attempt to overhaul the country’s health-care system—is no small matter.
But just when and how she should do that has been a source of debate among Mrs. Clinton’s campaign staff and advisors, who are worried not only about their candidate’s complicated history with the issue, but about being outflanked by the health plans of her rivals.
That all changed last week, when Mrs. Clinton’s closest rival, Barack Obama, presented his plan.
Mr. Obama’s proposal, in the form of his much-anticipated first major policy address, had much to recommend it to liberal proponents of health-care reform. But unlike the plan unveiled by John Edwards—and the one Mrs. Clinton is expected to present some time in the coming weeks—it lacked one thing: a cut-and-dry requirement that all Americans have health insurance.
Suddenly, Mrs. Clinton had an opening. “She does have an opportunity now to really distinguish herself,” said Dr. Irwin Redlener, a professor at the Mailman School of Public Health at Columbia University and an advisor to Mrs. Clinton on health-care policy. “It’s going to be universal. I don’t know how the mandates will be expressed, but there will be absolutely no ambiguity about the universality.”
Other, more politically neutral experts agreed.
“If Obama was exactly where Edwards was, then it really would be more difficult for her to have something slightly more moderate,” said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “So she has room to go on either side here.”
Mrs. Clinton will roll out her next health-care proposal, focusing on the quality of care, later this month, according to Dr. Redlener. Some components of that proposal, he said, would include expanding the use of electronic patient records to reduce life-threatening medical errors, such as different doctors prescribing potentially incompatible medicines to the same patient—a defect in care more common with older people who visit many specialists. Dr. Redlener said he also expects Mrs. Clinton to propose a dramatic change to the current incentive system by rewarding doctors and hospitals for keeping patients healthy rather than compensating them for the number of tests or surgeries they performed.
She will address the question of universal coverage later. According to Dr. Redlener, that, too, has been a subject of animated back-and-forth within the campaign.
“There was a tremendous amount of internal discussion about when Senator Clinton should release her plan,” he said. “There is certainly not universal agreement in the campaign even about when exactly the time of it should be. There were people that were saying, ‘You ought to be out there first to establish yourself.’ And Hillary’s call was: ‘I need to be ready when I go out there with this.’”
(When asked about Dr. Redlener’s account of dissension in the campaign, Clinton campaign spokesman Howard Wolfson said that he was unaware of any.)
Mr. Edwards had seemed to set the tone on the issue of universal coverage in February, when he announced a proposal to force private companies to compete with a government insurance provider to drive down prices. His plan also requires the purchase of insurance coverage by every American able to afford it.
“It’s truly universal,” said James Kvaal, the Edwards campaign’s policy director.
Three months later, Mrs. Clinton cautiously rolled out the first installment of a three-point plan with an address about cutting costs to the system, which some experts took as an indirect criticism of the estimated $120 billion price tag of the Edwards plan. In her speech, Mrs. Clinton also attempted to address the concerns of the 255 million people who pay insurance costs that they believe are too high.
“Here again, I think, is a good example of her having learned a very important lesson from her experiences in 1993 and 1994,” said Ron Pollack, the executive director of Families U.S.A., a nonprofit, non-partisan organization advocating universal health care. “She made a very smart decision to focus first on cost. While coverage is ultimately the moral issue in our health-care system, what most voters are concerned about is cost.”
But Mrs. Clinton’s speech amounted to more of a striptease than an unveiling. Whether by design or not, she withheld a comprehensive articulation of her plan until Mr. Obama had shown his.
The plan Mr. Obama duly put forth on May 29 took Mrs. Clinton’s campaign and health-care experts by surprise.
Paul Ginsburg, president of the Center for Studying Health System Change, a nonprofit, non-partisan research group, said he was “a little baffled” that Mr. Obama’s plan didn’t require universal coverage.
Jonathan Gruber, an M.I.T. economist who helped develop the health-care plans of Mr. Obama, Mr. Edwards and Mrs. Clinton, said that while the Obama proposal takes strides in making insurance more accessible and affordable, its lack of a requirement to make insurance obligatory for all Americans would mean that many of the people currently without coverage would stay that way.
“My estimates are, you can’t even get halfway to universal coverage without some mandate,” Mr. Gruber said. “Even when it’s affordable, healthy people won’t take it.”
Mr. Gruber, who played a key role in the formation of the ground-breaking plan in Massachusetts to provide universal coverage, said that he convinced then-Governor Mitt Romney to move to a mandate system in part by showing him that it would be the only way ultimately to insure a significant chunk of the uninsured population.
“The only benefit is the freedom of individual choice,” he said of Mr. Obama’s plan.
The Obama campaign disputes that characterization and argues that its plan is more realistic about taking steps that will eventually get to universal coverage, such as cutting the high costs that they say could make Mr. Edwards’ insistence on an insurance mandate untenable.
“The Obama health-care plan is a plan that brings down costs for all Americans and makes sure that every American gets health-care coverage,” said Bill Burton, a spokesman for the Obama campaign. “It won’t happen overnight; no plan says that it will happen overnight. But it will happen in due course through this plan.”
In response to Mr. Burton’s comments, Mr. Wolfson directed The Observer to a statement by the campaign’s policy director, Neera Tanden, that was released following Mr. Obama’s speech. The statement read, in part: “Senator Clinton believes that in addition to making healthcare more accessible, we have to achieve true universal healthcare so that every American has health care coverage.”
Dr. Redlener said he was taken aback by “how kind of meek Obama’s plan was. In 1995, this would have been brazen; in 2007, it’s kind of ho-hum. And where is the rest of it?”
Of course, Mrs. Clinton’s still-unannounced plan has yet to undergo that same level of scrutiny from health-care experts, who will compare it not only to those of her rivals in the Democratic primary, but to her own previous effort to reform health care as First Lady—the collapse of which nearly derailed her husband’s first administration.
“[Mr. Edwards and Mr. Obama] have forced her to come out with a plan,” said Mr. Blendon. “And a plan for her is riskier than for the other candidates.”
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