*For Democrats, Pragmatism On Universal Health Care*

By Perry Bacon Jr.
Washington Post Staff Writer
Tuesday, July 10, 2007; A01

In a conference call in January, the health-care debate within the Democratic
out before former senator John
who was in search of policy advice for his presidential campaign, and his
wife, Elizabeth.

On one side was Ezekiel Emanuel, a doctor and bioethics expert and the
brother of Rep. Rahm
arguing that the American health-care system is so riddled with
inefficiencies that it needs to be blown up and replaced by a plan in which
people can buy coverage themselves with a voucher.

On the other side was an economist from the Massachusetts Institute of
has become possibly the party's most influential health-care expert
a voice of realism in its internal debates.

"Far be it for me to lecture you on politics, Senator Edwards," Jonathan
Gruber recalled saying, and then he did just that. He told Edwards that
whatever the merits of Emanuel's idea, it just would not be politically
viable. Instead, Gruber argued for a more incremental approach, like the one
in Massachusetts<>he
helped write. Its central elements would be providing subsidies to
who are unable to pay for health care, increasing the number of those who
are enrolled in public programs such as Medicaid and creating a public
agency to help anyone ineligible for the programs buy health insurance.

A month later, when Edwards announced his health-care plan, he almost
completely sided with Gruber. And he is not alone. For the first time since
President Bill Clinton<>'s
plan for health-care reform, overseen by his wife, collapsed in 1994, the
leading Democratic presidential candidates are campaigning in favor of
universal health care. But in developing their specific plans, they are
embracing the pragmatic steps advocated by the MIT professor and a group of
similar-minded policy experts, many of whose ideas were shaped by their
first exposure to the perils of health-care politics 13 years ago.

"Plans which minimize the disruption to the existing system are more likely
to succeed than plans that rip up the existing system and start over," said
Gruber, who has consulted with the three leading Democratic campaigns about
their health plans. "It doesn't take a genius to see that. That's not to say
that plans ripping it up wouldn't be better -- I just think they're
political non-starters."

Two of those candidates, Edwards and Sen. Barack
Ill. <>),
have endorsed the idea of universal coverage and suggested ways to achieve
it, and the third, Sen. Hillary Rodham
is expected to outline her ideas in the next few months. Obama's plan does
not require adults to obtain health insurance, a distinction that Edwards
has tried to exploit because his aides say that without such a requirement,
Obama's plan would not ensure coverage for everyone.

While the war in
the campaign, polls show that Democratic primary voters rank
health care as their top domestic concern after the economy. To many
liberals, the health-care system is just as bad as it is portrayed in Michael
new documentary, "Sicko."

To move toward universal coverage, Edwards, Clinton and Obama have
approaches that borrow from the Massachusetts model. That plan, regarded as
one of the nation's most innovative, took key elements of the 1993 Clinton
plan and made them practical politically -- so practical that the plan was
enacted in 2006 by a Democratic legislature with support from a Republican
governor, 2008 presidential candidate Mitt

The original Clinton plan envisioned creating public agencies in states and
nationally to oversee health care, and setting guidelines about how much
insurance companies could charge and what benefits they would offer.

Edwards and Obama are proposing to create similar entities, but they would
mainly provide coverage for the uninsured. Clinton is likely to adopt a
similar policy, according to health-care experts who have spoken to her

The initial Clinton foray into health care required employers to provide all
their workers with insurance. Now Democratic candidates are telling
employers that they would not have to do that, although their plans would
require employers that do not offer insurance to pay a tax. And for those
who are happy with their insurance coverage, nothing would change, except
the candidates say it would be less expensive and more efficient through
systemic reforms such as computerized record-keeping.

A major component of the Massachusetts model is an "individual mandate"
requiring that people buy insurance or face a penalty, usually not receiving
a tax deduction. The idea is that once health insurance is affordable,
everyone should be required to have it and taxpayers should not have to
cover the bills of the uninsured.

Gruber championed this idea in Massachusetts, and over the past year he did
the same in Obama's office, on the phone with Edwards and in conversations
with Chris Jennings, Hillary
health policy guru. Edwards adopted it, and Clinton has suggested that she
supports it as well. Such a mandate was in her 1993 plan.

Obama aides argue that people fail to buy insurance because they cannot
afford it, not because they do not want it, so the senator from
not included a similar mandate in his proposals, focusing instead on
reducing costs. Political caution in part motivated the decision, concede
some Obama advisers who worry that such a mandate might be politically
difficult for a president to enforce.

Gruber told Obama advisers that they should include a mandate. He said that
without the mandate, Obama's plan would shrink the number of uninsured from
15 percent to 6 percent. Obama's aides said that they think they could
achieve universal care without a mandate, but that they would add one if
they did not.

"You get in your head that you cover 98 percent of people and you get yelled
at for 99 percent," said David Cutler, a
advising Obama. "Yeah, I'm a little surprised" by the attacks, he

Obama and Edwards have called for raising taxes on people who make more than
$250,000 to finance additional health-care spending. Clinton has suggested
she would look for savings in the health-care system to pay for her plan.

Massachusetts had a large amount of money already devoted to covering the
uninsured. But because the federal government does not, any of the
Democratic plans would involve increasing taxes or the deficit.

All three Democrats support a provision similar to another part of the
Massachusetts plan that would require businesses either to offer insurance
to their employees or pay a tax. Fourteen years ago, a similar proposal
helped drive opposition to Bill Clinton's heath-care plan.

Edwards and Obama have embraced one potentially radical idea: Their plans
each include an option for people to buy the kind of health coverage that is
offered by Medicare for older Americans. If most Americans chose that
option, it essentially would create a government-run health-care system.
Edwards, the most aggressive of the leading candidates in courting the
party's liberal base, mentions this aspect of his plan frequently, whereas
Obama almost never does.

Republican presidential candidates, wary of large plans that call for tax
increases, have depicted the Democratic proposals as "socialized medicine."
Romney is among them, even though the law he signed as governor of
Massachusetts has been a model for Clinton, Edwards and Obama. In fact, the
Democratic plans represent an attempt to balance the demands of a liberal
base and avoid anything that smacks of too much government intervention, the
accusation that helped kill the 1993 Clinton proposal.

Hillary Clinton's advisers, reasoning that reducing health-care costs is the
top priority for the 90 percent of voters who have coverage, have so far
outlined only the cost-cutting parts of her agenda. She will give speeches
later in the year on improving quality and insuring everyone, but her aides
wanted to talk about reducing costs first.

"You have to speak first on reducing costs and improve quality before
pouring more money into what people think in many ways is a sub-par system,"
said Gene Sperling, who was a top economic adviser to Bill Clinton and is
now helping Hillary Clinton's campaign.

But some health experts argue that it is hard to imagine the savings the
Democrats are touting without some painful measures, such as allowing
insurance companies to restrict the kind of procedures or the choice of
doctors that Americans have. "There is an idea you can somehow do all these
things controlling costs without anybody doing anything they don't want to
do," said John Sheils, who studies health-care plans at the nonpartisan
Lewin Group. "These are tough questions."

Clinton advisers concluded early on that whatever the bad memories of 1993,
she had to talk about health care. So she has been the candidate who has
acknowledged that the 1993 experience frames everything Democrats do on the
issue. "I've got the scars to show for it," Clinton said. "I've been through
it, but that just makes me more determined."

Obama has seemed the most reluctant to wade into this debate. At a
health-care forum in Las
March, he said that "every four years, somebody trots out a white
they post it on the Web" and nothing gets passed, suggesting that it was
more important to focus on building a political consensus on reforming
health care than on creating more complicated plans.

But the next month, when Victor Fuchs, an economist who studies health care
at Stanford University<>,
told some of Obama's advisers that the campaign should offer general
principles on health care and not a plan, the response surprised him.
Pundits in Washington would write that the campaign was not offering enough
details, they told him, so they had to offer a plan if only to preempt that

Ezekiel Emanuel has not been impressed by the candidates' efforts on health
care. When Edwards released his plan in February, he blasted it in an e-mail
to one of the candidate's aides, saying it was hard to figure out why
someone seeking the Democratic nomination was backing a health-care approach
crafted by Romney, a Republican.

"I don't think they're very bold," Emanuel said. "I don't actually think
they solve the problem."

Gruber disagrees. Yesterday he expressed satisfaction that Democrats have "a
sense of realpolitik, of understanding the limitations of what the American
voters will go for, while still moving toward the goal of universal


Michael Balter
Contributing Correspondent, Science
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