For Democrats, Pragmatism On Universal Health Care

By Perry Bacon Jr.
Washington Post Staff Writer
Tuesday, July 10, 2007

In a conference call in January, the health-care debate within the Democratic Party played out before former senator John Edwards of North Carolina, who was in search of policy advice for his presidential campaign, and his wife, Elizabeth.

On one side was Ezekiel Emanuel, a doctor and bioethics expert and the brother of Rep. Rahm Emanuel (D-Ill.), arguing that the American health-care system is so riddled with inefficiencies that it needs to be blown up and replaced by a plan in which people can buy coverage themselves with a voucher.

On the other side was an economist from the Massachusetts Institute of Technology who has become possibly the party's most influential health-care expert and a voice of realism in its internal debates.

"Far be it for me to lecture you on politics, Senator Edwards," Jonathan Gruber recalled saying, and then he did just that. He told Edwards that whatever the merits of Emanuel's idea, it just would not be politically viable. Instead, Gruber argued for a more incremental approach, like the one in Massachusetts he helped write. Its central elements would be providing subsidies to people who are unable to pay for health care, increasing the number of those who are enrolled in public programs such as Medicaid and creating a public agency to help anyone ineligible for the programs buy health insurance.

A month later, when Edwards announced his health-care plan, he almost completely sided with Gruber. And he is not alone. For the first time since President Bill Clinton's plan for health-care reform, overseen by his wife, collapsed in 1994, the leading Democratic presidential candidates are campaigning in favor of universal health care. But in developing their specific plans, they are embracing the pragmatic steps advocated by the MIT professor and a group of similar-minded policy experts, many of whose ideas were shaped by their first exposure to the perils of health-care politics 13 years ago.

"Plans which minimize the disruption to the existing system are more likely to succeed than plans that rip up the existing system and start over," said Gruber, who has consulted with the three leading Democratic campaigns about their health plans. "It doesn't take a genius to see that. That's not to say that plans ripping it up wouldn't be better -- I just think they're political non-starters."

Two of those candidates, Edwards and Sen. Barack Obama (Ill.), have endorsed the idea of universal coverage and suggested ways to achieve it, and the third, Sen. Hillary Rodham Clinton (N.Y.), is expected to outline her ideas in the next few months. Obama's plan does not require adults to obtain health insurance, a distinction that Edwards has tried to exploit because his aides say that without such a requirement, Obama's plan would not ensure coverage for everyone.

While the war in Iraq dominates the campaign, polls show that Democratic primary voters rank health care as their top domestic concern after the economy. To many liberals, the health-care system is just as bad as it is portrayed in Michael Moore's new documentary, "Sicko."

To move toward universal coverage, Edwards, Clinton and Obama have approaches that borrow from the Massachusetts model. That plan, regarded as one of the nation's most innovative, took key elements of the 1993 Clinton plan and made them practical politically -- so practical that the plan was enacted in 2006 by a Democratic legislature with support from a Republican governor, 2008 presidential candidate Mitt Romney.

The original Clinton plan envisioned creating public agencies in states and nationally to oversee health care, and setting guidelines about how much insurance companies could charge and what benefits they would offer.

Edwards and Obama are proposing to create similar entities, but they would mainly provide coverage for the uninsured. Clinton is likely to adopt a similar policy, according to health-care experts who have spoken to her campaign.

The initial Clinton foray into health care required employers to provide all their workers with insurance. Now Democratic candidates are telling employers that they would not have to do that, although their plans would require employers that do not offer insurance to pay a tax. And for those who are happy with their insurance coverage, nothing would change, except the candidates say it would be less expensive and more efficient through systemic reforms such as computerized record-keeping.

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