The Democratic presidential race is converging around an issue that has long been a mainstay of Democratic primary campaigns, but which is so far proving nearly as divisive as the Iraq war: universal healthcare.
A decade after the collapse of President Clinton's plan to overhaul the nation's healthcare system, Democrats are once again, in varying degrees, taking up the cause.
Nearly every White House hopeful is making broader access to affordable healthcare a campaign centerpiece. But while they may agree on the general goal, their plans are strikingly different in scale and approach, generating sharp clashes over questions of cost and feasibility.
The result is a revealing proxy battle over the fundamental direction of the Democratic Party. At one end of the spectrum are those offering sweeping, costly proposals - which opponents tag as a return to "big government." At the other end are those pushing for incremental, less expensive reform - which critics see as timid and ineffective.
Even strategists are struck by the intensity of disagreements so early in the primary season. "Campaigns tend to be a little less dramatic than this, in terms of ... [policy] issues," says Bill Carrick, an adviser to Representative Gephardt. "This has instantly become a big, serious debate."
The emergence of healthcare as a campaign focus is hardly surprising. With healthcare costs soaring, and the number of uninsured Americans estimated at more than 41 million and rising, a recent Gallup survey showed that 79 percent of Americans are worried about future availability and affordability of healthcare. Polls also show the public is far more inclined to trust Democrats than Republicans on the issue - so it could be a key component of the eventual nominee's campaign.
To some extent, as Mr. Carrick admits, the flurry is attributable to Gephardt, who threw healthcare into the spotlight a few weeks ago by introducing a sweeping plan to cover nearly all of the nation's uninsured, at an annual cost of more than $200 billion. The other candidates, unwilling to cede the terrain, have been scrambling to respond. This week, former Gov. Howard Dean released a plan of his own, as did Rep. Dennis Kucinich last week. Sen John Kerry is expected to release his plan Friday, with other candidates following shortly.
Yet the issue has taken on a larger significance, highlighting sharp philosophical divides within the field and the party. These differences exploded at the Democratic debate in South Carolina, where several candidates attacked Gephardt's healthcare plan as unwieldy and inefficient: Sen. John Edwards charged it took money from working families, while Sen. Joseph Lieberman likened it to "big-spending Democratic ideas of the past."
Democrats have been calling for universal healthcare since the days of Truman. But the failure of the Clinton plan - which helped fuel the 1994 Republican take-over of Congress - led many within the party to pull back in recent years, focusing instead on piecemeal efforts, such as a patient's bill of rights or adding a prescription-drug benefit to Medicare. In the 2000 campaign, former Sen. Bill Bradley campaigned on a broad plan to offer health insurance to all Americans - and lost the nomination to Vice President Al Gore, who advocated a far narrower approach.
Many Democrats maintain that with looming deficits and a Republican-controlled Congress, sweeping healthcare reform is less feasible than in years past. "The political climate is even less receptive to a total reform, in one step, of our healthcare program today than it was in 1993," says Sen. Bob Graham.
But others advocate a bolder stance. Not only has the problem worsened, they say, but the party's dispiriting losses in 2000 and 2002 made clear that an incremental approach won't excite activists. Some point to President Bush's relentless push on core GOP issues such as tax cuts, and argue their party should project a similar image of ideological ambition and consistency.
"There's something smart and proper about putting a big healthcare plan on the table - even if it makes for a big political target," says a Democratic strategist. "As a party, that's how you show determination and principle."
Almost all of the current plans offered do reflect lessons of the Clinton experience. Aside from Representative Kucinich, who is advocating a government-run program subsidized by a payroll tax, all the candidates are proposing to expand access by building on the current system.
"The Clinton plan failed because it looked like a government takeover," says Will Marshall, president of the Progressive Policy Institute, and a Kerry adviser. "What people are looking for is a way to universal coverage that doesn't entail a major expansion of government bureaucracy."
Still, the plans released so far tend toward the broader end of the scale - though with significant differences. While Gephardt offers a new federal subsidy for all employers, and mandates that they provide coverage, Dean would expand federal and state programs for low-income families, such as the Children's Health Insurance Program (CHIP), and would offer new tax credits to help pay for coverage. He estimates his approach would cost $88 billion a year, less than half of Gephardt's plan, and would cover slightly more Americans.
Senator Kerry's proposal is expected to expand programs like CHIP, for roughly the same cost as Dean's plan. But Kerry places more emphasis on cost containment, with a measure to reduce the price of prescription drugs.
Other candidates, such as Lieberman, Edwards, and Graham, are likely to release far narrower plans, an approach they will argue is both more fiscally responsible and politically feasible.