The health care debate in this year's presidential contest has been largely boiled down to an argument over degree: Democrat John F. Kerry proposes an ambitious, costly expansion of health coverage, while President Bush takes a far more modest approach.
In terms of cost and number of newly insured people, the shorthand is accurate. But from a philosophical perspective, Bush is proposing a 180-degree shift away from the current employer-based system and toward individual coverage.
"I pity the poor voters," said Drew Altman, president of the nonprofit Kaiser Family Foundation, which tracks health policy. "The debate has done little to clarify what really are huge and basic differences between the candidates."
The political debate is being waged against a grim backdrop. Since 2001, the number of people lacking health insurance has climbed by 5 million to 45 million, or 15.2 percent of the population, according to this fall's Census Bureau report. Insurance premiums are up more than 50 percent, and some employers are scaling back or dropping coverage altogether.
Not since the 1992 presidential race has anxiety over health costs risen so high in voters' minds -- and perhaps no other issue in this year's campaign offers such divergent views.
Kerry, after convening a team of experts more than 18 months ago, devised a plan that builds on the current public-private insurance system. Though cost estimates on the 10-year proposal vary from $653 billion to $1.3 trillion, analysts agree that the plan would cover about 26 million more Americans.
Bush, largely drawing on ideas he introduced in the 2000 campaign, offers tax credits and new purchasing pools to help individuals and small businesses buy coverage. The costs would be significantly less: $90 billion to $200 billion over a decade. But the question of how many people would be covered is hotly debated; estimates range from 2 million to the campaign's claim of 17 million.
Although Bush has wrongly accused Kerry of a "government takeover" of the health system, Kerry's plan does envision broad expansions of Medicaid and the State Children's Health Insurance Program, which are run jointly by state and federal officials. He would open the programs to children at 300 percent of the poverty level (about $56,000 for a family of four), parents at 200 percent of the poverty level and childless adults who earn less than $9,000 a year.
"If you're uninsured, that might not be so bad, but it is not private insurance," said Gail Wilensky, a health official in the George H.W. Bush administration who is informally advising the president's campaign.
Kerry would also permit any individual or small business to purchase coverage mirroring the insurance given to federal employees, including members of Congress. This would provide access to a variety of health plans, but the price is unknown.
The most dramatic new element in the Kerry package is his plan for the government to reimburse employers who choose to participate as much as 75 percent of the cost of "catastrophic" cases, or those exceeding $30,000 in the initial years. The reinsurance plan is designed to reduce premiums by 10 percent and take much of the guesswork out of risk adjustment.
Bush's health proposals are part of his larger "ownership society" theme, aimed at making individuals both more responsible for and more in control of their destinies. For years, he has advocated unsuccessfully for a $1,000 tax credit for individuals ($3,000 for families) to buy health insurance. That would barely put a dent in a standard $9,000 premium, though it could pay for high-deductible coverage.
At the heart of Bush's approach are new, tax-deductible health savings accounts, which enable businesses and workers to contribute into a fund modeled loosely after 401(k) retirement accounts. Opponents suggest that the largely untested accounts would attract the healthy and wealthy, leaving the sick and poor in ever more expensive risk pools.
"You get less coverage, and you pay more," said Chris Jennings, a former Clinton administration official informally advising the Kerry team.
Neither candidate has a blueprint for covering every American, and neither has proposed any revolutionary ideas for tackling skyrocketing medical bills.
In a sense, both men would simply shift costs: Kerry from employers and individuals to taxpayers, and Bush from employers to individuals. Though the candidates might object to such simplifications, Wilensky and Jennings largely accepted them.
"We recognize there are now, and increasingly in the future, people without employer-sponsored insurance," Wilensky said. "We need to have another system in place for them, and this is a way to begin moving another system in place."
Having the government pay a portion of catastrophic cases and cover more low-income workers was a conscious choice, Jennings said.
"To govern is to choose," he said. "John Kerry is prioritizing affordable and reliable health insurance for American businesses and families over an excessive, unnecessary tax cut for the top 1.4 percent of the nation."