A Sharp Divide on Health Care
Much Debate Turns On Mass. Program

By Perry Bacon Jr.
Washington Post Staff Writer
Sunday, November 18, 2007; A05

The debate over how to overhaul the nation's health-care system is underscoring a dramatic chasm between the two parties, as Democrats battle over which candidate will most quickly expand health insurance to cover all Americans while GOP contenders compete over who can best minimize the role of both government and employers in delivering care.

The landmark legislation that GOP presidential candidate Mitt Romney signed last year as governor of Massachusetts requiring everyone in the state to have health insurance is now at the center of disputes in both nominating contests.

On Thursday, former Tennessee senator Fred D. Thompson's campaign dubbed the law a "tax penalty" because Massachusetts will deny those who don't sign up for insurance by the end of this month a $219 income tax exemption.

In the Democratic presidential debate in Las Vegas the same day, Sen. Hillary Rodham Clinton (D-N.Y.), whose national health-care plan borrows many elements of the Massachusetts approach, criticized rival Barack Obama's proposal on the issue, arguing that it would leave 15 million of the 47 million currently uninsured without coverage because it doesn't require the purchase of health insurance.

"The Democrats are as a group saying the federal government should guarantee health insurance coverage for all Americans; the Republicans are saying we do not need a big federal program," said Robert Blendon, a professor of health policy at the Harvard School of Public Health.

Changing the nation's health-care system has been a Democratic priority since the Truman administration, but as polls show independent voters increasingly concerned about the issue, Republicans have also become more vocal in outlining proposals. Sen. John McCain (R.-Ariz.) says he gets more questions on the stump about health care than any issue except the Iraq war.

The failure of the Clinton administration and the Democratic Congress to pass a major health-care bill in the early 1990s left politicians on both sides wary of the issue. Several states have since begun to move on their own to expand health insurance availability to more residents, and many states have looked to what Romney and a Democratic legislature did in Massachusetts in 2006. That plan relied on three critical elements: increasing the number of low-income people who got coverage through Medicaid, offering financial assistance for middle-income people to buy private insurance and adding regulations to the private insurance market to make it easier for people to buy it. All the leading Democratic presidential candidates adopt those three ideas in the proposals they hope to apply to the whole country.

The Massachusetts plan also called for an "individual mandate," a requirement that everyone get insurance or face a fine. Clinton and former senator John Edwards (N.C.) adopted this idea, while Obama (D-Ill.) argues that people who opt against getting insurance do so not because they don't want it, but because they can't afford it.

Price is a major barrier. Of the 47 million people without health insurance, about 9 million live in households that make more than $60,000 a year, while 30 million are families whose annual income is below $40,000, according to data from the nonpartisan Henry J. Kaiser Family Foundation.

Obama aides argue that they can achieve universal coverage without requiring it, and they dispute Clinton's contention that 15 million Americans would remain uninsured. Independent experts, however, largely agree that without mandating insurance, some middle-income people will not buy it and some low-income people eligible for federal programs will not sign up. As Massachusetts tries to enforce its plan, almost half of the state's more than 500,000 uninsured have not enrolled, despite the tax penalty.

The dispute is in some ways overstated; all the Democratic presidential health-care plans are likely to be changed dramatically by Congress, and Clinton and Edwards have not said how they would penalize people who did not get insurance.

On the GOP side, the debate is turned on its head. Romney, while defending his plan in Massachusetts, has argued that Democrats forced the inclusion of some of its more ambitious aspects and he has not proposed anything like it for the nation. All the GOP candidates except Romney have spoken out strongly against the idea of mandates, arguing the government should not require anyone to purchase health insurance.

"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.