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For Democrats, Pragmatism On Universal Health Care

A major component of the Massachusetts model is an "individual mandate" requiring that people buy insurance or face a penalty, usually not receiving a tax deduction. The idea is that once health insurance is affordable, everyone should be required to have it and taxpayers should not have to cover the bills of the uninsured.

Gruber championed this idea in Massachusetts, and over the past year he did the same in Obama's office, on the phone with Edwards and in conversations with Chris Jennings, Hillary Clinton's health policy guru. Edwards adopted it, and Clinton has suggested that she supports it as well. Such a mandate was in her 1993 plan.

Obama aides argue that people fail to buy insurance because they cannot afford it, not because they do not want it, so the senator from Illinois has not included a similar mandate in his proposals, focusing instead on reducing costs. Political caution in part motivated the decision, concede some Obama advisers who worry that such a mandate might be politically difficult for a president to enforce.

Gruber told Obama advisers that they should include a mandate. He said that without the mandate, Obama's plan would shrink the number of uninsured from 15 percent to 6 percent. Obama's aides said that they think they could achieve universal care without a mandate, but that they would add one if they did not.

"You get in your head that you cover 98 percent of people and you get yelled at for 99 percent," said David Cutler, a Harvard economist advising Obama. "Yeah, I'm a little surprised" by the attacks, he said.

Obama and Edwards have called for raising taxes on people who make more than $250,000 to finance additional health-care spending. Clinton has suggested she would look for savings in the health-care system to pay for her plan.

Massachusetts had a large amount of money already devoted to covering the uninsured. But because the federal government does not, any of the Democratic plans would involve increasing taxes or the deficit.

All three Democrats support a provision similar to another part of the Massachusetts plan that would require businesses either to offer insurance to their employees or pay a tax. Fourteen years ago, a similar proposal helped drive opposition to Bill Clinton's heath-care plan.

Edwards and Obama have embraced one potentially radical idea: Their plans each include an option for people to buy the kind of health coverage that is offered by Medicare for older Americans. If most Americans chose that option, it essentially would create a government-run health-care system. Edwards, the most aggressive of the leading candidates in courting the party's liberal base, mentions this aspect of his plan frequently, whereas Obama almost never does.

Republican presidential candidates, wary of large plans that call for tax increases, have depicted the Democratic proposals as "socialized medicine." Romney is among them, even though the law he signed as governor of Massachusetts has been a model for Clinton, Edwards and Obama. In fact, the Democratic plans represent an attempt to balance the demands of a liberal base and avoid anything that smacks of too much government intervention, the accusation that helped kill the 1993 Clinton proposal.

Hillary Clinton's advisers, reasoning that reducing health-care costs is the top priority for the 90 percent of voters who have coverage, have so far outlined only the cost-cutting parts of her agenda. She will give speeches later in the year on improving quality and insuring everyone, but her aides wanted to talk about reducing costs first.

"You have to speak first on reducing costs and improve quality before pouring more money into what people think in many ways is a sub-par system," said Gene Sperling, who was a top economic adviser to Bill Clinton and is now helping Hillary Clinton's campaign.

But some health experts argue that it is hard to imagine the savings the Democrats are touting without some painful measures, such as allowing insurance companies to restrict the kind of procedures or the choice of doctors that Americans have. "There is an idea you can somehow do all these things controlling costs without anybody doing anything they don't want to do," said John Sheils, who studies health-care plans at the nonpartisan Lewin Group. "These are tough questions."

Clinton advisers concluded early on that whatever the bad memories of 1993, she had to talk about health care. So she has been the candidate who has acknowledged that the 1993 experience frames everything Democrats do on the issue. "I've got the scars to show for it," Clinton said. "I've been through it, but that just makes me more determined."

Obama has seemed the most reluctant to wade into this debate. At a health-care forum in Las Vegas in March, he said that "every four years, somebody trots out a white paper, they post it on the Web" and nothing gets passed, suggesting that it was more important to focus on building a political consensus on reforming health care than on creating more complicated plans.

But the next month, when Victor Fuchs, an economist who studies health care at Stanford University, told some of Obama's advisers that the campaign should offer general principles on health care and not a plan, the response surprised him. Pundits in Washington would write that the campaign was not offering enough details, they told him, so they had to offer a plan if only to preempt that criticism.

Ezekiel Emanuel has not been impressed by the candidates' efforts on health care. When Edwards released his plan in February, he blasted it in an e-mail to one of the candidate's aides, saying it was hard to figure out why someone seeking the Democratic nomination was backing a health-care approach crafted by Romney, a Republican.

"I don't think they're very bold," Emanuel said. "I don't actually think they solve the problem."

Gruber disagrees. Yesterday he expressed satisfaction that Democrats have "a sense of realpolitik, of understanding the limitations of what the American voters will go for, while still moving toward the goal of universal coverage."

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