Although some profess to see little difference between the health care proposals of Vice President Gore and former senator Bill Bradley, the two Democratic presidential candidates do in fact offer very different answers to the key questions: Who deserves help buying insurance, who should pay for it, and how much? The plans merit careful analysis and a fair debate, which could clarify a number of choices for all American voters.
Gore has tailored a narrow set of health insurance subsidies for a conservative Congress that is nervous about ignoring 44 million uninsured Americans. He would target parents of children who are eligible for current government programs, Medicaid and the new Children's Health Insurance Program (CHIP). He would also increase the number of children potentially eligible for CHIP and offer new tax credits for some small firms and for individuals without access to group insurance. His plan is modest, efficient and safe.
Bradley's plan is bolder. He would require parents to cover their children and would offer subsidies to all low-income Americans, whether or not they are parents, and whether or not they are eligible for a public program or are currently uninsured. Thus his plan is as much about financial relief for working but low-income Americans who now buy health insurance as it is about expanding coverage.
Bradley would transfer most Medicaid recipients into mainstream health plans and allow all low-income people to buy private insurance plans through the same program that federal workers and Congress now use. Finally, his plan would create a new tax deduction for all premium payments, whether made through work or on one's own. Bradley's plan is more ambitious and expensive, and therefore riskier.
What do these plans reveal about each man?
Gore appears to have concluded that substantially expanding health insurance coverage is not a major national priority. All of his measures, taken together, would expand coverage only modestly.
Bradley holds that health insurance coverage is a national objective worthy of significant public resources. He is interested in equity--giving all people with the same low incomes the same subsidy--as well as coverage. Gore emphasizes target efficiency--namely, concentrating new subsidies on the uninsured. Pursuing equity is expensive--more of Bradley's new spending would go to reduce costs for the currently insured low-income population than to provide new coverage.
Interestingly, though his objectives are more moderate, Gore relies almost exclusively on expanding public programs. Bradley is willing to spend a lot of tax money to get most Americans into private plans.
Who would win the most under Gore's vision? Parents and children who would be made eligible for public programs. Who is left out? The working low-income people who are struggling to cover their families now, and those who have decided they can't afford private insurance but who make too much money to qualify for public insurance. Gore, in the name of fiscal prudence, offers them little relief.
Bradley's winners extend to a much larger number--the entire low-income population--since they would all receive the same subsidy for buying their own private health insurance plan, whether or not they are currently insured. The losers are higher-income taxpayers, who would either forgo tax reductions or pay higher taxes. Bradley would change who pays for health care more than inject new money into the system; he thinks that equity in access to health care is in our society's long-term interest.
What risks and unanswered questions are raised by these two approaches?
Bradley would move most current enrollees out of Medicaid and allow millions of low-income Americans to purchase private insurance through the federal employees' program. Some fear this would prevent current Medicaid enrollees from getting all the services they need. Indeed, Bradley might have to either scale back benefit guarantees or spend even more tax dollars. Similarly, allowing low-income people into the federal employees' plan could pose difficult administrative challenges.
The Gore plan would have to overcome the disappointing enrollment experience in CHIP and in Medicaid. Gore appears to believe that slightly increased financial incentives would induce states to spend more of their own money to expand coverage a lot, and that these efforts would be successful on a scale never before observed.
Aside from technical questions, Gore's faith in the states highlights differences in the candidates' views on federalism. Gore supports joint federal-state responsibility for health insurance, which has political virtues but leaves national coverage objectives hostage to individual states' willingness to pay. State variation in access to coverage is huge.
Bradley, by contrast, claims that widespread private health insurance coverage is a national priority and an exclusively federal responsibility. He would abolish state variations in subsidies, even though this would cost a lot more federal money than we are spending now.
Properly explained, these two proposals present the Democratic electorate with a clear choice. They also identify key questions for Republican candidates' plans: Who should get help buying health insurance, and who should pay? But if the Democratic debate remains mired in attack politics, no meaningful debate across party lines is likely. For the rising number of uninsured Americans, that would be a tragedy.
The writers are senior analysts in the health policy research group at the Urban Institute.