A Sharp Divide on Health Care

"It's not a good idea," former New York mayor Rudolph W. Giuliani said last week in Tampa, "because it's an idea that moves you in the direction of socialized medicine."

In his attacks on the Romney proposal, Giuliani likens the Massachusetts model and the Democratic proposals to the health-care systems in European countries such as Britain, where doctors are paid directly by the government and health care is subsidized through taxes for everyone. Neither element is included in the Massachusetts plan or those being offered by the top Democrats.

But under some of the Democratic proposals, more than 16 million Americans could be put on Medicaid or the State Children's Health Insurance Program, two programs for low-income people, ideas that GOP contenders have not advocated.

"We need to go as far as we can to get everyone insured within the private marketplace," said Vin Weber, one of Romney's top policy advisers.

The top Democratic candidates want to raise taxes, particularly on the 2 percent of American families who make more than $250,000 a year, to finance more than $100 billion a year in new health-care spending.

Romney and Giuliani favor an approach President Bush has proposed: allowing people to deduct health-care spending from their taxes. This would do little for many of the uninsured, millions of whom pay little or nothing in income taxes because they do not earn enough. McCain, too, favors better access for the individual purchase of health insurance, but his method would be a refundable tax credit of $2,500 per individual and $5,000 for a family, which, unlike tax deductions, can go to people of all incomes.

Each of those plans offers an incentive for the dramatic change Republicans want to see in the health-care system: individuals buying health care through the private market rather than their employer. Fewer than 15 million Americans get their insurance in this manner, compared with more than 150 million who receive it through their employer.

Giuliani aides said the former mayor would eventually like to see upward of 50 million people insured through private insurance.

Democrats do not want to change the employer-based system and would tax employers who do not offer insurance for employees.

Many experts are skeptical of the GOP approach, because under current conditions it is often more difficult to buy health insurance as an individual. People with preexisting conditions face high fees and can often be denied coverage.

The Democrats would address this issue by requiring insurance companies to issue coverage to anyone who applies, with the government subsidizing the portion they cannot pay for, an approach some of the GOP candidates oppose as too much government intervention.

"The insurance market often does not offer affordable coverage to people who are older," said Paul Ginsberg of the Washington-based Center for Studying Health System Change.

The Republicans would spend less money changing health care: While their campaigns have not offered precise estimates, the plans are not expected to cost anywhere near the annual estimated $100 billion the Democratic proposals would come with.