AMERICAN HEALTH CARE - December 17, 2007

As the US presidential primary campaigns head into their last frenetic days before the voting begins, the issue landscape over which next fall's general election will be fought is shifting. Attitudes toward the Iraq war have not changed, but hints of progress and a lower daily toll of US combat dead – and the inability of a narrowly Democratic Congress to force a change in course – have made Iraq, though still the leading issue in most polling, a less dominating issue than a year ago. At the same time, economic unease, due especially to a troubled housing market, has pushed economic concerns to the forefront.

         
In this shifting environment, the cost and availability of health care is likely to emerge as a major campaign issue next fall. Health care, primarily its cost, consistently rates near the top of domestic concerns in polling, both on its own merits and as a stand-in for broader economic anxieties. Candidates of both parties have put out health care proposals, Democrats more prominently. Democratic presidents since Truman have made proposals for national health care insurance programs, historically resisted by Republicans as socialized medicine. Thus the prominence of health care on the political terrain generally favors Democrats, just as crime, were it more prominent as an issue, would favor Republicans.

     
Among the leading Democratic contenders, John Edwards' and Hillary Clinton's health care proposals are essentially similar. Each calls for allowing people to retain their existing private health insurance – generally a plan offered by their employer, the US norm since the Second World War. This is the political rock on which Hillary Clinton's previous health care initiative foundered in the 1990s. While about one in seven Americans has no health insurance, the majority do, and most are fairly satisfied with their current plan. Their anxieties revolve around losing it.
         

The Edwards and Hillary plans both address this anxiety by allowing people to keep their existing plans while offering a backup: In effect, buying into either Medicare or the health plans offered to federal employees. The effect over time might be to make Medicare the norm for American health care – "single payer" through the back door. For much of the business community, ideological distaste for a large government program may be outweighed by the desire to escape a growing burden, including the costs of negotiating with health insurers.
     

Barack Obama's plan is similar in structure but significantly less ambitious. In particular, while Edwards and Hillary both mandate that individuals not already covered purchase insurance or buy into the government plan (with subsidies), Obama's plan imposes no mandate. This is appealing to the American libertarian impulse, which has a distaste for mandates. However, the plan likewise does not guarantee coverage, posing a risk that healthy young adults in particular will simply take their chances – and so avoid paying any share of health insurance costs, increasing the burden on other payers.
       

On the Republican side, Mike Huckabee raised interest and eyebrows by suggesting in a debate that Americans should get the same health care plan that Congress has, or else that Congress should make do with what average Americans have access to. Huckabee's campaign website, like those of his GOP rivals, is quick to denounce federal intrusion in health care, and in fact Huckabee's "brand" in health care policy is prevention (a theme into which he weaves his own success in losing 100 pounds, some 40 kilograms). Nevertheless, Huckabee's debate remarks were startling, nearly evoking John Edwards' populism.
Other Republican candidates' health care policy proposals are relatively simple. Since they reject a larger government role in health care, they have little to propose. The Democrats' proposals, except for that of left-leaning Dennis Kucinich (who calls for a national single-payer system resembling Canada's), are bewilderingly complex. All of them are essentially cobbles, because the existing American health care delivery system has been cobbled together over decades, and the plans seek to reform (and possibly supplant) the existing system rather than sweeping it aside wholesale. Few voters probably ever read the full proposals; they are written to show commitment to the issue and withstand a degree of media scrutiny.
Curiously, as important as the issue is to Democrats, health care policy has scarcely figured in the primary campaign so far. That is, while health care is a prominent theme in the candidates' stump speeches, and came up regularly in the pre-primary debates, it has not become a major point of contention. Unlike the war in Iraq, it is a large dog that has not barked in the night of the primary season. This might seem all the more remarkable because Hillary Clinton – still the Democratic frontrunner, though challenged by rising support for Obama – is so strongly associated with the sweeping health care proposal she championed during Bill Clinton's presidency in 1993-94.
           

A couple of factors can be suggested as contributing to the failure of differences on health care policy to become a key issue in the Democratic primaries. One is that the differences even between Obama's plan and Hillary's (or Edwards') are muted and fairly technical. The one time insurance mandates came up in a debate, the exchange between Obama and Hillary, though heated, was so oblique that few watchers may have known what the argument was about.
             

More broadly, Hillary's 1990s effort at health care reform cuts both ways, for both her and her rivals. She can claim credit for the attempt – and rebut her opponents' contention that she embodies the status quo – but must then admit that it came up short, precisely for lack of the political and policy skills she now claims as her strength. Her response is that she learned from the experience, but the failure still weighs on her. On the other hand, her primary opponents cannot call too much attention to her failure without reminding Democratic primary voters that she was author of the boldest Democratic social policy initiative in decades.
It is possible that health care policy will still emerge as a genuine issue of contention in the primary season, at least on the Democratic side where the issue is most salient to the primary electorate. Given the abbreviated primary season, however, the primary campaigns from now forward are likely to be tactical, mobilizing their grass roots organizations and hammering themes already established. Thus it is unlikely that health care policy differences will come front and center in the primaries after not having done so in the positioning phase.
            

In the general election campaign – which will commence, effectively, as soon as the two parties' prospective nominees are known – the prominence of health care policy as an issue will be a measure of whether and how much the overall political terrain favors the Democrats, as does currently. If the argument next fall is primarily about terrorism or immigration, it will be a sign that Republicans have the initiative; if it is about health care or Iraq, a sign that Democrats have the initiative.

Rick Robinson

--------------------

Author of the article holds B.A. degree in Economics from the University of California in Los Angeles (UCLA) and M.A. degree in English from California Polytechnic State University in San Luis Obispo, California . Mr. Robinson worked as a county-level campaigner in Dukakis (1988) and Clinton (1992) presidential campaigns. He presently works as a journalist and political commentator.

--------------------

Related articles:

Obama and America's Original Sin - April 7, 2008

My House Divided - March 24, 2008

Will Florida and Michigan Determine Next U.S. President? - March 12, 2008

The Continuing Democratic Race - March 10, 2008

Foreman vs. Ali 2 - February 15, 2008

Super Tuesday Truth - February 8, 2008

Into the Stretch: Landscape before Super Tuesday– February 2, 2008

Turnaround! The New Hampshire Primary Results - January 10, 2008

Out of the gate: Obama makes history - January 5, 2008

Mike Huckabee Story: "From out of nowhere..." - December 27, 2007

At the Starting Gate - November 15, 2007

Iowa and New Hampshire - October 4, 2007

A fifty/fifty nation - September 8, 2007

Obama: a foreign policy visionary or neophyte? - August 12, 2007

Democratic contenders - July 3, 2007

Immigration debate - May 10, 2007