Health-Care Gap
Democratic candidates tackle the coverage crisis.

Saturday, June 9, 2007

THE THREE leading Democratic presidential candidates have now put forward 2 1/2 health-care plans. Former senator John Edwards was first with a broad proposal to require that all individuals have health insurance coverage; Sen. Barack Obama (Ill.) followed with a similar but less far-reaching version, and Sen. Hillary Clinton (N.Y.) accounts for the remaining half a plan. This is not a criticism: She gave a speech last month on containing health-care costs, and she plans to offer details down the road about improving quality and expanding coverage; we'll write separately about her proposals.

What's striking about the Democrats' approaches is their similarities -- and how far they have moved from the cautious incrementalism of the 2004 presidential race to tackle more directly the problems of the 47 million Americans without health insurance. Mr. Obama's plan is less bold than the Edwards model. Mr. Obama would require parents to obtain coverage for their children, as Mr. Edwards proposed in 2004; Mr. Edwards would mandate coverage for both children and adults.

Both would set up pools to make insurance available at reasonable prices. Both would prevent insurance companies from cherry-picking the healthiest enrollees; both would provide a choice between private plans and a government-run plan based on Medicare. Both would provide subsidies to those who could not afford insurance and would roll back the Bush tax cuts for the wealthy to help pay the cost. Both would require that employers provide coverage for workers or pay into a fund for the uninsured.

This is a sensible approach to a system that simultaneously costs too much and helps too few. Unless Americans are ready to move to a single-payer system -- and even these emboldened Democrats aren't making that leap -- a pay-or-play employer mandate coupled with reforms to make insurance more affordable for individuals and small businesses is a sensible approach. Just ask California Gov. Arnold Schwarzenegger (R), or -- not that he mentions it very often on the campaign trail -- former governor Mitt Romney (R), whose Massachusetts health-care plan included a requirement for employers to offer coverage or pay a "fee."

Edwards's approach is preferable to Obama's because it is less susceptible to being undermined by the cost-shifting created when the uninsured end up being treated at emergency rooms. Mr. Obama argues that the problem of the uninsured is mostly a matter of affordability, in which case solving the price problem would do the trick. If not, he says, a mandate could come later, when costs have been driven down enough to make it fair. Still, the Obama plan could leave a third of those currently uninsured lacking coverage.

Both candidates, though, have moved the health-care debate forward with their proposals, and there is more to come on the Democratic side. It's too bad that none of the candidates has the courage -- or political foolhardiness, depending on how you look at it -- to take on the regressive and counterproductive tax deductibility of employer-sponsored health insurance and level the tax playing field with individually purchased insurance. But the Democrats' engagement presents a marked contrast to the Republican field's relative silence on health care.

Click here for other editorials in the Ideas Primary series.