Clinton unveils final piece of health plan

Washington -- Thirteen years after then first lady Hillary Rodham Clinton's universal health care plan died, presidential candidate Sen. Hillary Rodham Clinton (D, N.Y.) is pushing the issue on the national stage. Clinton's title is not the only thing that has changed. This time, she's sharing the national spotlight, and her ideas have evolved.

The third and final part of Clinton's overall health reforms -- the American Health Choices Plan, unveiled Sept. 17 -- in many ways mirrors those of her two main Democratic rivals for the presidency. Clinton released proposals to contain health care costs and improve quality earlier this summer.

Like former North Carolina Sen. John Edwards, Clinton would require everyone to have health insurance, although Edwards wouldn't do so until the rest of his plan made it affordable. Sen. Barack Obama, (D, Ill.), would cover all children. The three candidates would allow people with employer-sponsored health insurance to keep it, promote health information technology and offer new public health insurance plans designed to be more affordable.

Certain provisions differ. Clinton would make taxable a portion of employer contributions for above-average health benefits for employees earning more than $250,000 a year. While Clinton's and Edwards' plans would offer tax credits to individuals to help them buy insurance, Clinton's proposal also would offer tax breaks to small businesses.

But Clinton is separated from her competition mostly by her experience. Neither Edwards nor Obama have failed at the issue the way Clinton did in 1993 and 1994, when the plan presented by her presidential task force amounted to little more than a 1,200-page report and a lesson in humility. Yet Clinton stuck with the issue.

"I learned that people who are satisfied with their current coverage want assurances that they can keep it. Part of our health care system is the best in the world, and we should build on it. Part is broken, and we should fix it," she said.

Health policy experts offered a wide range of opinions on Clinton's new plan, but most gave her credit for a better political presentation this time. The American Health Choices Plan is eight pages long and states its intentions more clearly. "It's less ambitious and complex; easier for people to understand," said Paul Ginsburg, PhD, president of the Center for Studying Health System Change, a nonpartisan research organization.

Clinton reform, now and then

It's easy to draw both parallels and contrasts between Clinton's 2007 plan and the 1993 proposal.

Although the 1993 plan allowed individuals to keep employer-sponsored health insurance that met a basic standard, the plan's cornerstone was providing health benefits that could not be taken away.

The 1993 plan would have given states the power to set up regional alliances to negotiate with health plans on behalf of consumers. The health plans would have had to meet minimum standards for coverage, quality and service set by a national board. Individuals working for businesses with fewer than 5,000 employees would have enrolled in one of these plans and would have paid 20% of the costs, with employers picking up the other 80%.

Today's proposal would give people the choice between their existing private coverage and new health plans based on federal employee benefits and Medicare. Clinton would require everyone to have health insurance but not to enroll in the regional, managed-competition insurance networks of the 1993 plan.

"For middle income Americans who have insurance, her plan doesn't change anything," said Robert Blendon, ScD, a professor of health policy and political analysis at the Harvard School of Public Health.

The new plan would force health plans to enroll applicants no matter their health status and renew policies automatically. Clinton also would limit insurance company profits.

"A lot of her basic beliefs are the same," said Joseph Antos, PhD, a health care scholar at the American Enterprise Institute, a conservative think tank. Clinton is still a 1930s Democrat, he said, but he credited her with realizing that overnight reform won't work.

Clinton said she better understands today what it takes to accomplish significant national reform. "Having spent six years in the Senate, I know that fixing health care will require political will to get the votes we need, and it will take a movement for change, a solid national consensus for reform that can withstand the impact of the special interests."

Medical societies -- including the American Medical Association and the American Academy of Family Physicians -- support the idea of providing health coverage to all Americans. "We encourage each candidate to develop a proposal to cover the uninsured and urge all Americans to vote in the upcoming primary and general elections with the issue in mind," said AMA President-elect Nancy Nielsen, MD, PhD.

Outgoing AAFP President Rick Kellerman, MD, said: "Anything that moves toward every American having coverage is great."

But neither organization is endorsing a candidate or a plan. The AMA -- as a member of the Health Coverage Coalition for the Uninsured -- supports offering refundable, advanceable tax credits to help pay for health insurance and improving SCHIP and Medicaid enrollment.

Republicans offer plans

Just as the leading Democratic presidential candidates are united in attempting to cover all Americans, Republican candidates are lining up with proposals to decrease the government's role in health care.

"There's a real values debate going on in this country," Dr. Blendon said. "This is a big battle between the parties' views of the future."

Republicans, such as former New York City Mayor Rudolph Giuliani and former Massachusetts Gov. Mitt Romney, released plans to offer health coverage to a portion of the 47 million uninsured.

Both candidates favor incentives for states to enact their own reforms, such as insurance deregulation, plus tax reform to help individuals buy health insurance and medical liability reform.