Clinton's new gambit on healthcare

In a presidential primary season dominated by the Iraq war, the No. 1 domestic issue roars onto center stage Monday as Sen. Hillary Rodham Clinton (D) of New York unveils her proposal for healthcare reform.

For Senator Clinton, the front-runner for the Democratic nomination, the issue is fraught with risks. In 1993 and 1994, she oversaw the failed effort by her husband, former President Clinton, to remake healthcare in America. The old Clinton plan, which would have mandated coverage for all employees through health maintenance organizations, was lampooned by opponents as a government takeover. Mrs. Clinton was also criticized for operating in secrecy.

Now, the former first lady is seeking to turn that failure into a positive – and, so far, is succeeding. A recent poll by the nonpartisan Kaiser Family Foundation shows that, among all the presidential candidates, voters see Clinton as placing the biggest emphasis on healthcare. She tops the list with a plurality of 27 percent, followed by Sen. Barack Obama (D) of Illinois with 6 percent. Among Democrats, Clinton is also by far the candidate seen as best representing their views on healthcare, with 35 percent. Among Republican voters, former New York Mayor Rudolph Giuliani was the top choice, with 8 percent.

"Senator Clinton starts off with an edge on health," says Dean Altman, president of the Kaiser Family Foundation. That's "not because the voters have scrutinized the details of anyone's plan, and obviously she's only released pieces of hers so far, but just because they so closely associate her with the issue."

On the stump, Clinton herself often refers to her abortive healthcare reform in the '90s, a failure that played a significant role in the voters' rebuke of her husband during the 1994 midterms, when the Republican Party seized control of both houses of Congress. But she tries to spin that failure into a positive, telling voters that her efforts show how deeply she cares about the issue and that she has "the scars to show for it."

The last piece of Clinton's health plan, to be announced in a speech Monday in Des Moines, Iowa, will focus on insuring the uninsured, a segment of the population that has swelled to 47 million people in the US, out of a population of 300 million. According to published reports, citing Clinton aides speaking on background, the senator's proposal would require insurance companies to accept all applicants for coverage and would limit insurers' ability to charge higher premiums because of preexisting conditions.

The plan, these aides and advisers say, would also aim to make health insurance more affordable for those who already have it. She aims to have universal healthcare in the United States by the end of her second term, a goal analysts call optimistic.

Clinton has already unveiled portions of her healthcare plan. They include: a "prevention initiative" to help people avoid contracting preventable conditions, focus on improving care for the chronically ill, establishment of a public-private "best practices institute," easing restrictions drug imports, requiring Medicare to negotiate for lower drug prices, and computerization of healthcare records.

Achieving such reform would require bringing on board an array of stakeholders, including government, insurance companies, the pharmaceutical industry, physicians and hospitals, employers, labor, and citizens. Clinton hinted at the magnitude of the task last week in a forum sponsored by the liberal website Huffingtonpost.com: "We've got to have a political consensus in order to withstand the enormous opposition from those interests that will have something to lose in a really reformed healthcare system."

Clinton is the last of the major Democratic candidates to announce a healthcare plan. Senator Obama's plan aims to cover most of the uninsured by creating a new public plan. Of the top-tier Democratic candidates, former Sen. John Edwards of North Carolina aims to cover all of the uninsured by 2012. Both Obama and Mr. Edwards would pay for their plans by eliminating tax cuts on high-income Americans.

The Republican candidates approach the issue differently, aiming to boost coverage by providing tax incentives that make it easier for consumers to buy coverage from private insurers. Mr. Giuliani would provide a tax deduction of up to $15,000. Former Gov. Mitt Romney of Massachusetts is not proposing a nationalized version of the statewide healthcare reform he instituted, which requires residents to purchase health coverage. Instead, he believes solutions should be reached state by state, with the federal government playing a supporting role through tax incentives and flexibility in the use of federal healthcare funds.

Whether healthcare emerges as a major factor in how voters select the nominees remains to be seen. But Mr. Altman of Kaiser foresees a major debate on healthcare during the general election, in which different visions between the two parties are already clear.

"There's no question there will be a lot of mud-slinging and demagoguery," Altman says. "Already, we've heard the Republicans calling the Democratic approach socialized medicine, and for all we know, the Democrats will call the Republican approach Dickensian capitalism. Beneath all that, there are actually very different, sincerely held ideology and policy beliefs about which way healthcare should go."