By Perry Bacon Jr. and Anne Kornblut
Washington Post Staff Writers
Tuesday, September 18, 2007; A01

Sen. Hillary Rodham Clinton yesterday unveiled a proposal to provide health insurance to all Americans, placing herself at the center of an issue that provided perhaps the greatest setback of her political career.

In a speech in Des Moines, the Democratic front-runner said she would expand insurance to the 47 million people who do not already have coverage and would attempt to reduce costs for others without spawning a massive new bureaucracy. In a far different political environment than the one that turned her efforts to establish universal health care into a fiasco in her husband's first term, Clinton offered a more modest approach than she took as first lady and head of a White House task force in 1993.

"Today's plan is simple yet doable," Clinton said. ". . . This is not government-run. There will be no new bureaucracy."

Similar to proposals offered by her chief Democratic rivals, former senator John Edwards (N.C.) and Sen. Barack Obama (Ill.), Clinton's plan -- with an estimated $110 billion annual price tag -- would seek to build on the existing health-care system but would make it easier for adults without health insurance to buy it through tax credits.

Health care has emerged as the paramount domestic issue of the 2008 race, and all of the Democratic contenders are embracing aggressive approaches to broadening coverage. But for Clinton, it also is a reminder of some of the early lows of her husband's administration. While even Edwards and Obama agree that her travails in the health-care debate of the early 1990s give her a vast base of knowledge and experience on the issue, they point to the failure as an argument that the experience Clinton so often touts is not necessarily an asset.

"She's the candidate with the most expertise, but she's also the candidate with the most negative history," said Jonathan Gruber, a health-care expert and professor at the Massachusetts Institute of Technology who talked to all three leading Democratic campaigns about their plans. "Will the public be more swayed by her experience or her bad history?"

Clinton said she has learned from her failure on the issue. In an interview before unveiling her proposal, she stressed that she has a "better understanding of the relationship between the president and Congress" than she did 15 years ago. "Having worked on both ends of Pennsylvania Avenue now," she said, "I think I have a better chance of being successful with this legislation."

She added that "there is a much broader consensus on the need for reform now," as health-care costs have outstripped inflation and the growth of income in the past 15 years. "You see businesses and labor together on this, Republican and Democratic governors, and the fact that we are in a global market, where our health-care costs are a competitive disadvantage -- all of that is different."

Bill Clinton campaigned on the promise of expanded health care in the 1992 presidential race, but the "Health Security Act" crafted by Hillary Clinton and her task force was abandoned as congressional Democrats and the administration bickered over the details and Republicans and insurance companies adamantly opposed it.

Now, with states such as Massachusetts mandating universal care and even Republicans such as California Gov. Arnold Schwarzenegger pushing similar initiatives, Clinton's proposal is not as politically daunting as it might have been even four years ago. The labor unions being courted by the candidates have essentially demanded that candidates offer universal coverage, and the plans Edwards and Obama have offered are so expansive that there was little short-term risk to Clinton in offering an ambitious scheme.

"The race is advanced to the point where you can't sneak by with a plan without too much detail in it," said Erik Smith, a Democratic strategist and veteran of presidential politics.

Republican presidential candidates have offered much more limited ideas for reforming health care, eschewing proposals for universal health care and instead touting changes to the tax code that they say would make it easier for individuals to purchase private insurance but that would not expand coverage dramatically, as the Democrats propose. Eager to establish themselves as anti-Clinton, several were quick to take aim at her proposal yesterday.

"Senator Clinton's latest health scheme includes more government mandates, expensive federal subsidies and more big bureaucracy -- in short, a prescription for an increase in wait times, a decrease in patient care and tax hikes to pay for it all," Katie Levinson, communications director for former New York mayor Rudolph W. Giuliani, said in a statement.

At a news conference, former Massachusetts governor Mitt Romney said " 'Hillarycare' continues to be bad medicine."

Clinton's campaign, aware of the inevitable attacks, planned a careful rollout of its health-care proposal. Rather than giving a single speech on health care, she gave two addresses earlier this year on improving health-care quality and reducing costs. Her aides argued that it was particularly important for Clinton to show that her approach to reforming health care would be different this time around and focused on rebutting charges that her plan was not like the 1993 proposal.

Clinton said her plan would "not create a single new government department, agency or bureaucracy." She also took great pains to emphasize that her plan would not be radical. She emphasized that if people in the United States currently like their health-care plan, her proposal does not require them to change it.

"And I think it will and should be reassuring" to people who like their current coverage, said Gene Sperling, an economic adviser in the Clinton White House now working for the senator from New York.

Clinton's campaign dubbed the new proposal the American Health Choices Plan, and the candidate used the words "choice" and or "choose" more than a dozen times in her 45-minute address. Her proposal allows people to enroll in a public plan similar to Medicare or the program federal employees use, or to get health care through a private insurer, essentially the same options that the other Democratic candidates have proposed. Clinton decided to make choice a key feature, aiming at voters who do not like their current care and want to have options for improving it.

"What is unique to her and that no one has really done is this emphasis on choice," said Andrei Cherny, a Democratic strategist.

The plan remains a far cry from the one Clinton and the controversial 500-person task force assembled behind closed doors at the start of Bill Clinton's first term. That proposal would have required all Americans to enroll in regional health plans that were administered by either their state or the federal government. It also sought to reform the health insurance market by, in effect, creating price controls on how much insurance companies could charge.

The new plan would expand government funding for programs for low-income adults and children, and it would require employers to either insure their workers or pay a tax. It would be funded in part by not renewing tax cuts passed under the Bush administration for households that make more than $250,000 a year, something Edwards and Obama have also proposed.

Insurance companies, which aired a series of potent ads featuring a couple named "Harry and Louise" who elaborated on their concerns about the Clinton plan, remain a target. Her proposal would require insurers to offer health-care coverage to any person who applies for it, although it includes provisions for the government to help subsidize the cost.

Edwards said yesterday that if elected, he would submit legislation on his first day in office that would end health-care coverage for the president, all members of Congress and all political appointees on July 20, 2009, unless they have passed a universal health-care measure. In a statement, Obama said, "the real key to passing any health care reform is the ability to bring people together in an open, transparent process that builds a broad consensus for change," a jab at the Clinton task force of the 1990s.

Clinton made clear in the address that she is willing to work with Congress and that her plan is only outlining principles for reform.

"We're not writing every single detail of this plan," said Laurie Rubiner, her top health-care policy adviser, adding that Clinton learned her lesson in trying to be overly prescriptive. "We're going to leave a lot of this to the congressional committees."

But Clinton's advisers and the candidate herself have been clear about the direction they wanted to go, to the point that some outside experts who were consulted thought the process was really just window dressing.

And while Clinton aides have emphasized the lessons they learned from the debacle of the 1990s, they have also pointed out what they believe to be the sources of the proposals made by Obama and Edwards: the 1993 Hillary Clinton plan.

Staff writer David S. Broder contributed to this report.