Now that George W. Bush has a plan for health care it's official: The issue is back.
Four years ago a presidential candidate wouldn't be caught dead talking about health care. Talk about the uninsured, health alliances and universal coverage pretty much died with the Clinton health plan. Health moved to the bottom of the public opinion polls.
But as the number of uninsured Americans began creeping up to its current 44 million and as more and more people have become disillusioned with the rigors of managed care, it became an issue that Bush finally decided this week he could not cede to his opponent, Al Gore.
"Bush really anguished with his advisors, worried if he didn't come up with anything significant, maybe it would be better not to be active on the issue," said Robert Blendon, a Harvard University professor who has tracked public opinion on health care for more than a decade. "They decided there's enough interest to do something on this problem or else it would look like he was neglecting a major issue."
The cornerstone of the Texas governor's plan is to give the uninsured up to $2,000 in tax credits so they can go on the open market and buy coverage.
Gore's plan would mainly help children and their families. His proposal relies on an expansion of Medicaid, the health-care plan for the poor, and the Child Health Insurance Program, the state-administered federal program that helps low-income children.
While the details of their plans are different, both take an incremental approach. There are no sweeping plans on either candidate's mind. And that's probably just fine with the majority of the American public. "This is not the era to try to cover everyone," says Blendon.
Not surprisingly, Democrats and health-care advocates charge Bush's plan doesn't go far enough. They say the $2,000 in tax credits he is proposing wouldn't enable the poor to buy health insurance because family policies typically cost more than that.
But Republicans and business interests say Bush has it right -- that the purchase of health care should remain a free-market issue. They want to avoid a government-run system at all costs.
Robert Desposada, president of the Hispanic Business Roundtable, says even if $2,000 a year won't pick up the whole tab for a family's insurance, it will be enough of a help that business may pick up the rest.
"The fact is the problem with a good chunk of the uninsured is that these are people who work for small businesses and the service industry whose companies do not offer health insurance," said Desposada, who owns a public relations firm in Alexandria, Va.
"This is an approach I think will be helpful. I can't give my employees $2,000 a year. I can give you a part of the difference that it will take for you to get health insurance."
Bush's plan is also similar to bipartisan proposals in both the Senate and House. House Majority Leader Richard Armey, R-Texas, and Rep. Cal Dooley, D-Calif., introduced a bill a couple of weeks ago that is also tax-credit based. The same measure has been introduced in the Senate by Sen. John Breaux, D-La., and Sen. Bill Frist, R-Tenn., who is also a heart-transplant surgeon.
But Families USA, a health-care advocacy group that has been pushing for universal coverage, calls Bush's proposal "a trivial response to a serious problem."
Families USA executive director Ron Pollack says that a typical family health plan costs $5,000 to $6,000 a year and even with the $2,000 tax credit, that leaves a $3,000 to $4,000 balance that won't be picked up by employers and would be unaffordable for low-wage families. To many health-care advocates, Gore's proposal looked paltry when set beside former Sen. Bill Bradley's plan for getting to universal coverage quickly.
But if forced to choose between Bush's plan and Gore's plan, they will side with the vice president. Beyond the issue of how many people would be covered under each plan, Brookings Institution senior fellow Henry Aaron worries that Bush's plan might erode the employer-based coverage by creating a shift toward individual coverage.
"If we unwind the system of workplace-based coverage, short of having subsidies larger than anyone is talking about, then we'll discover at the end of the day that we have fewer people insured than more," Aaron contends. Since companies buy health insurance policies in bulk, the process keeps costs down, Aaron said. Without that buying power, the individual market has more overhead and administrative costs.
Blendon sees a road to compromise on the issue. While he doesn't believe any such deal could surface during the campaign season, Blendon thinks the two proposals could work simultaneously.
"I could see that for people at the most modest end the public programs are extended, but for people who are working and have a bit higher income you could have tax credits," Blendon says. "That's a basis for a compromise."