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Clinton and Obama Offering Different Paths to Universal Coverage

Once the Democratic presidential race narrowed to a two-person contest, the campaign became a debate mostly over style and personality rather than substance and policy differences.

But health care is one issue where Sens. Barack Obama (Ill.) and Hillary Rodham Clinton (N.Y.) are offering two distinct visions of the policy course they would follow.

Although Clinton’s 1993 single-payer proposal is off the table, she still offers a more expansive health care plan than Obama. Both candidates want to create a government insurance plan available to all and ban insurance companies from denying anyone coverage. But Clinton mandates that every American have some form of health insurance. Obama’s plan mandates only that children get covered.

[IMGCAP(1)] In debates, Clinton has charged that Obama’s lack of mandates would leave 15 million Americans uninsured. Obama responds that his opponent would garnish wages from poor workers who can’t afford health care.

“Barack Obama believes that the reason people don’t have health care is that they can’t afford it, not that they need to be forced to buy it,” Obama’s campaign said in a written response to questions, echoing a line the candidate uses on the campaign trail.

Clinton counters that insuring everyone is the best way to reduce costs because it creates a shared pool of risk and guarantees that people don’t game the system by waiting until they get sick to apply for insurance.

[IMGCAP(2)] “The only way you get universal coverage is to have a mandate,” Clinton policy director Neera Tanden said in an interview. “Every health care expert will say the best way to maximize cost reductions is to get everyone in the system.”

Asked whether Obama would prefer mandates but thinks his plan is more palatable to the American people and more likely to gain Congressional approval, his campaign responded: “Obama strongly believes that meaningful cost reduction measures must take effect before a federal individual health insurance mandate can be considered.”

The Clinton campaign believes Obama has miscalculated if he believes he’s found a middle ground that would insulate him from Republican attacks that he is pushing too large a government role in health care, according to Tanden.

Referring to likely Republican presidential nominee Sen. John McCain (Ariz.), Tanden said: “As we have already seen in the health care debates, Sen. McCain attacks both of us for mandates. He attacks Obama for the mandate on kids and us for the mandates on everybody. [Obama’s plan] seems to be of little political benefit.”

She added: “Many of Hillary’s political advisers advised her not to support mandates because it would make her vulnerable to Republican attacks. We thought that would be in the general election. We didn’t think our primary opponent would attack us for mandates.”

Considering the long campaign and the tight race, it’s not surprising that the candidates’ differences have been magnified. But both have at times played down those distinctions and instead contrasted their proposals with McCain’s. Among the Clinton and Obama plans’ many similarities are that both:

• Allow people to keep their current private plan if they so choose;

• Offer a public plan similar to the one offered to federal employees, including Members of Congress;

• Ban insurance companies from denying anyone coverage;

• Offer subsidies to those with low incomes;

• Expand Medicaid and the State Children’s Health Insurance Program;

• Require employers that do not offer health insurance or health subsidies to their employees to contribute to the national plan;

• Enforce their mandates by requiring proof of insurance at places people can’t avoid — schools, hospitals, jobs, etc.;

• Claim to reduce a family’s health care costs by over $2,000 annually through a combination of health IT improvements, medical malpractice reform, preventive care, allowing the reimportation of prescription drugs and a host of other measures.

One other notable difference besides mandates is the secondary options after the public plans. Clinton also offers a more basic option modeled after Medicare, while Obama would create an exchange that acts essentially as a health care adviser.

Obama’s system, called the National Health Insurance Exchange, would point consumers to a plan that best suits them. It would “act as a watchdog and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible,” according to Obama’s campaign Web site.

To be included in the exchange, an insurance company must offer benefits at least as generous as the new public plan and have reasonable premiums.

“If an uninsured American calls either the exchange or the public plan, they will be given the opportunity to review and discuss the available plans in both programs and determine which plans make the most sense for their economic and health situation,” the Obama campaign said in its written response.

Although private health insurers will not be forced to join the exchange, they will have an incentive to because the exchange will coordinate with local governments, schools and community centers to make the public aware of the best insurance plans in the exchange, according to the campaign.

But in the end, the debate all comes back to mandates — two plans that offer health care to all but one with a total mandate.

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