Which Democrat's Health Plan

By LAURA MECKLER
December 5, 2007; Page A8

While the leading Democratic presidential candidates agree on most policy issues, a sharp dispute has emerged: Who would do more to provide health coverage for the uninsured?

Sens. Hillary Clinton and Barack Obama have been engaged in a bitter back-and-forth over whose health plan covers more people. Former Sen. John Edwards has jumped in, saying his plan is the best of all.
• The Players: Hillary Clinton, Barack Obama and John Edwards all claim to have universal health-care proposals.
• The Background: Clinton and Edwards, but not Obama, would require all Americans to have insurance.
• The Bottom Line: Mandates may be needed to get everyone insured, but it's unclear if these plans provide enough subsidies to make the mandates affordable.

The argument concerns whether the government should require all Americans to get insurance. Mrs. Clinton and Mr. Edwards would require people to get insurance, either through work, a government program or new health marketplaces that all three candidates promise to set up. Mr. Obama would only require that children be insured.

Other elements of their plans are similar, including subsidies to help lower-income and even middle-income families pay premiums, and various proposals to cut the cost of health care. The candidates say they would pay for their plans by rolling back President Bush's tax cuts for upper-income earners and by savings in health spending through various measures.

None of the Republican candidates has proposed a universal health plan. But with the race tight and health care the No. 1 domestic issue for Democrats, the differences among Democrats have become a point of continuing tension.

Mrs. Clinton charges that Mr. Obama's plan would leave 15 million people without insurance. Outside experts agree that number is in the ballpark. If people aren't required by law to buy insurance, many won't. There are millions of children, for instance, who remain uninsured, even though they qualify for free or subsidized government programs.

In addition, all three candidates want to bar insurance companies from rejecting sick people or charging them more. But it is hard to require companies to insure expensive sick people if they aren't guaranteed that cheap healthy people will balance them out.

On the campaign trail, Mrs. Clinton has attacked Mr. Obama for his plan, saying it betrays the Democratic principle of universal coverage. Her campaign has demanded that he take down an advertisement that claims his plan "covers everyone."

Mr. Obama has replied that her attacks are more about politics than substance; they didn't come, he noted, until she lost ground in the polls. But his advisers don't dispute her central charge. Rather, they claim Mrs. Clinton's plan would also leave millions without coverage.

Obama adviser Austan Goolsbee argues that if Mrs. Clinton's health plan is enacted, she will have to waive the mandate for millions of people. That is because, he says, there isn't enough money for subsidies to make health insurance affordable enough for people to buy it.

"You can't put in a mandate until health care is affordable," he says. He predicted that a Hillary Clinton administration would wind up exempting 20% of the uninsured, or about 10 million people. That is the percentage of uninsured adults who were exempted in Massachusetts, the only state to try an individual mandate.

That view may not be true. Ken Thorpe, a health-policy expert at Emory University who has advised all three major Democrats, said he ran cost estimates for the Clinton plan at the Clinton campaign's request, and found there should be enough money to make insurance affordable for all. He said he ran three scenarios with varying levels of subsidies -- from $100 billion a year to $120 billion a year. The campaign chose one in the middle: $110 billion.

If it turns out that isn't enough money to make health premiums affordable, Mrs. Clinton would have to spend more on subsidies, one of her health-care advisers said.

But, the adviser said, it is wrong to assume that 20% of Americans will be exempted. It is impossible to say for certain, because the campaign has not explained how large the subsidies will be or who will qualify for them.

The Obama plan does some other things to get people insurance. It allows adults up to age 25 to stay on their parents' insurance even if they aren't in school. And it attempts to lower the cost of insurance overall through a reinsurance plan, whereby the federal government would cover some expenses of some of the most costly patients.

Outside experts note that the Clinton and Obama plans propose spending about the same amount of money, while Mr. Obama uses some of his to pay for the reinsurance plan -- an initiative that could cost tens of billions of dollars. That should help lower premiums across the board, but it means there would be less available for direct subsidies.

Amid the Clinton-Obama dispute, Mr. Edwards, who was the first to propose a universal coverage plan, has tried to jump into the debate. He notes that he has been much more specific than Mrs. Clinton has about how he will enforce the mandate. Indeed, Mrs. Clinton has suggested some options but has not made as clear a statement about enforcement.

Under the Edwards plan, people will have to prove their have insurance when they file their taxes, and the government will seek to collect back premiums, with interest, for those who refuse to get it.

None of the candidates want to talk about the fact that even if their plans worked out exactly as designed, none would cover all 47 million uninsured people in the U.S. That's because several million of the uninsured -- estimates put it up to seven million -- are illegal immigrants, and none of the front-runners include them in their programs.

Write to Laura Meckler at laura.meckler@wsj.com