Democratic Health Plans More Alike Than Different

While Democratic presidential hopefuls Hillary Clinton and Barack Obama continue to draw battle lines over the differences in their health-care reform policies, some health policy experts say the disparities between their plans are far less significant than either potential candidate might lead you to believe.

Indeed, both senators plan to promote health insurance for individuals who do not have employer-provided health care and who do not qualify for other existing federal programs. And through their plans, both hope to move the country one step closer to universal health-care coverage.

But, the question that the candidates are battling over is whether it is better to mandate that all uninsured Americans buy insurance, or rather to lure the uninsured into buying it through more subsidies and lower insurance rates?

It's a detail that may evade all but the most wonkish political followers.

"The one thing [health policy experts] agree on: The two plans are much more alike than it seems with the current emphasis on their different views on mandates," said ABC News medical editor Dr. Tim Johnson.

But to the rival campaigns, the subtle differences in how universal health coverage is implemented represent sacred ground.

Mandate … or Man-Don't?

Clinton's campaign has espoused the idea that her health-care plan, which mandates individual health insurance for every American, is more progressive and inclusive that Obama's plan, which would mandate only that children are insured. Clinton maintains that covering everyone will help reduce health-care costs overall.

However, according to some health policy experts, a mandate to buy health insurance is not necessarily the end-all-be-all to achieving universal health-care coverage.

"While it is almost certainly impossible to get to universal coverage without a mandate, I'm skeptical that a mandate will actually achieve universal coverage," said Michael Tanner, director of Health and Welfare Studies at the Cato Institute in Washington, D.C. "At the very least, a mandate raises questions about how it will be implemented and enforced."

According to health policy experts, the success of such a mandate would depend on both the size of subsidies available to pay for the coverage of the uninsured as well as how the government plans on penalizing those who refuse to enroll in any of the available insurance programs.

"The only country that has ever attained universal coverage without mandates is Switzerland. Or, at least they came very close," said Joe White, chair of the department of political science at Case Western Reserve University. "But they provided very strong financial incentives, both negative and positive, for people to get insurance — much stronger than I've seen any American politician propose. And even the Swiss eventually decided to move to mandates a few years ago."

Clinton has offered no details as to how she plans on penalizing those who do not enroll in one of the available insurance plans.

Obama, however, believes that an initial mandate is unrealistic, as it forces people to buy health insurance before it becomes affordable to them. Instead, he proposes that the government push for lower health-care costs first, considering a mandate only afterward if it becomes necessary.

Indeed, many experts contend that without offering a comprehensive strategy for lowering overall health costs, a mandate to achieve universal coverage will still fall short of solving the health policy issues we face today.

According to White, the burden of mandates weighs heavily on the poor and underserved populations who simply cannot afford even the cheapest of available insurance plans. Even if these citizens were forced to obtain insurance, they still might not be able to afford the high price of treatment costs in our country.

"After all, a relatively low-income person with high-deductible coverage may not be able to afford services within the deductible, so not even get to the insurance," White explained. "How does this constitute coverage?"

In fact, even in Massachusetts, where a law was passed in 2006 requiring every citizen to obtain or purchase health insurance, only about 300,000 of the projected 500,000 uninsured Massachusetts residents gained health coverage by the end of 2007.

And in addition to the failure of this plan to provide universal coverage for all Massachusetts citizens, hospitals have been left with unpaid bills and mounting expenses to care for the uninsured.

Moreover, just as it remains unclear whether or how the Massachusetts government will find the money to meet the rising costs of its subsidies, it's equally uncertain how either of these candidates plans to implement cost controls to afford such subsidies.

"No presidential candidate has urged cost controls that stand a chance of making a visible difference," said Dr. Alan Sager, director of the Health Reform Program and the Program in Health Policy and Management at the Boston University School of Public Health. "This has been generally ignored."

A Blended Approach?

Mandates or not, most public health experts agree that the best solution may be some combination of the two plans, allowing for both mandates and lower health-care costs so insurance can be afforded by all.

After all, both Democratic candidates' health-care proposals include stipulations that aim to drive down the number of uninsured Americans — about 44.8 million people, or 15.3 percent of the population, according to 2005 statistics from the U.S. Census Bureau.

These proposed changes, coupled with mandatory coverage of children, will cover a large chunk of uninsured Americans. Government subsidies to individuals and employers, creating insurance pooling mechanisms and expanding current public programs may help pick up the remainder.

As it stands, every other affluent nation in the world either provides a health-care system to which all legal residents are entitled or requires that all legal residents purchase health insurance by making special arrangements for low-income citizens to help them purchase insurance. In other words, the United States is the only affluent country that makes health insurance voluntary for citizens younger than 65.

But just as details now provide a battleground for the two potential Democratic candidates, they could pose a hazard later when it comes to implementing health-care reform, should either of them get the chance. While both Obama and Clinton clearly favor universal coverage, neither has provided a clear-cut explanation for the necessary steps to achieve their proposed health care reform goals.

But health policy experts stress that Clinton and Obama will have to modify their dreams as they attempt to put these policies in action.

"Sen. Clinton starts with the actuarial and ethical design that any good policy wonk would adopt," explained Uwe Reinhardt, the James Madison professor of political economy at Princeton University. "Sen. Obama appears to believe that Americans will always want to have the cake and eat it too— in other words, imagined rights to health care but no responsibility to contribute to its financing."

ABC News Medical Editor Dr. Tim Johnson and Dan Childs contributed to this report.