Sooner or later, the political argument about expanding access to healthcare always returns to the same intractable question: Who pays the bill?
The healthcare proposal that Democratic presidential hopeful Barack Obama released last Tuesday, though vague on many details, will sharpen that debate in illuminating ways.
Mr. Obama's plan is important first for what it is not. Like the other top Democratic presidential contenders, he rejects the left's growing support for a government-run, single-payer healthcare system. Instead, he proposes to reinforce the existing system, under which the vast majority of Americans receive coverage either through their employers or through government programs such as Medicare and Medicaid.
To cover most (but not all) of the roughly 45 million Americans without health insurance, Obama advances ideas that split the bill between individuals, government, and business. His first step would be to require parents to insure their children. Then he proposes to expand eligibility for government programs for the poor and to offer subsidies to help other uninsured individuals buy coverage through a new, nationwide purchasing pool modeled on the insurance available to federal employees. Finally, Obama would require all but the smallest employers to provide insurance for workers or else pay about 6 percent of their payroll to help the government fund the cost of covering those employees.
That last proposal marks a crucial turn in the healthcare debate. President Bill Clinton included a mandate for employers to insure their workers in the 1993 universal coverage proposal designed largely by his wife, Hillary Clinton. But, since small business groups helped sink the Clintons' plan, Democrats have shied away from such a mandate.
This year, though, John Edwards, another 2008 Democratic hopeful, has already proposed a mandated employer contribution as part of his universal coverage plan. Democratic Gov. Ed Rendell in Pennsylvania and Republican Gov. Arnold Schwarzenegger in California have incorporated the idea into state-level universal coverage initiatives. The universal healthcare plan Massachusetts adopted last year also included a mandatory, though token, employer payment. Obama, who has stressed national reconciliation, underscored the idea's resurgent mainstream appeal by joining that list.
Democrats are trying to attract business to comprehensive reform by emphasizing ideas that would cut their costs. Senator Clinton last month proposed that health insurance companies, as a condition of participating in federal programs, be required to cover both preventive and disease-management services that could help reduce premiums. Obama echoed her last Tuesday. Obama also revived the best policy idea of Sen. John Kerry's 2004 campaign: a proposal for Washington to fund most of the bill for high-cost patients once their annual healthcare bills exceed a fixed level. Shifting those catastrophic expenses to government would lower employer premiums. So might Obama's surprisingly sharp-edged proposals to limit insurance company profits.
The best chance for reaching (or even nearing) universal healthcare coverage is a system of shared responsibility that requires government, individuals, and business to all contribute. The ideas percolating in the states and among the leading Democratic presidential contenders move in that direction. But unless big employers finally act on their stake in reform, healthcare for all is likely to remain out of reach – at great cost not only to the national interest but to corporate America's own bottom line.
• Ronald Brownstein is the national affairs columnist for the Los Angeles Times. ©2007 Los Angeles Times Syndicate.