New York Sen. Hillary Clinton's new proposal for universal health insurance aims to be bolder than the plan offered by Sen. Barack Obama, D-Ill., while still being more pragmatic than her failed 1993-94 effort to reform the nation's health-care system.
"I hope the headline will read, 'Hillary is back and we're going to get it done this time,'" Clinton said last week during an online Democratic forum sponsored by Yahoo and the Huffington Post.
Clinton's proposal, which comes with a price tag of $110 billion per year, would require every American to carry health insurance and offer federal subsidies to help reduce the cost of coverage.
The plan would require large businesses to offer insurance or contribute to a government-run pool that would help pay for those not covered.
Clinton's inclusion of an individual mandate is a key difference with the plan offered earlier this year by Obama. The Illinois Democrat would only mandate that children have health insurance.
Clinton Would Require Health Insurance
The purpose of requiring all individuals to have health insurance is to address the free-rider problem that occurs when emergency rooms, which are required under federal law to provide a certain level of treatment to everyone, are forced to treat a patient who is unable to pay.
When someone without insurance or ability to pay winds up in an emergency room, those costs shift to taxpayers as well as to those who have insurance.
Requiring everyone to have health insurance will impose new costs on those who can afford coverage but currently choose to go without it.
The goal, however, is to lower costs for those already in the system and to improve the level of preventive care going for the previously uninsured.
Edwards, Clinton Aim at Obama Plan
By calling for an individual mandate, Clinton will be able to join former North Carolina Sen. John Edwards, in criticizing Obama for proposing a plan that stops short of covering all Americans.
"We have a threshold question about whether we're going to have truly universal care," Edwards said during a June 3 Democratic debate. "The New Republic has estimated that his plan will leave about 15 million people uncovered."
The debate's moderator — CNN's Wolf Blitzer — did not ask Clinton for her opinion on an individual mandate, but the former first lady appeared to be nodding as Edwards lambasted the Illinois Democrat.
Obama has countered criticism directed at him from proponents of individual mandates by promising to work to fill the gaps that remain and by saying the focus should be on making health insurance more affordable.
He also has argued that people still go without auto insurance in states that make such policies compulsory.
To avoid some of the pitfalls that killed her original effort to overhaul the nation's health-care system, Clinton is going out of her way to assure people who are satisfied with the status quo that her plan will not force them to change.
"If you like the plan you have, you keep it," Neera Tanden, Clinton's policy adviser, told The Associated Press. "If you're one of tens of millions of Americans without coverage or don't like the coverage you have, you will have a choice of plans to pick from and you'll get tax credits to help pay for it."
Clinton has dropped some of the more controversial aspects of her failed '93-94 plan.
In particular, she has dropped her earlier support for a global cap on annual increases in insurance premiums. She also has dropped rules that would have restricted the number of insurance companies that could compete in different regions.
Robert Blendon, professor of health policy and political analysis at Harvard University, has identified both of those measures as contributing to the enormous opposition her plan drew from the insurance industry.
While dropping the more onerous insurance regulations, Clinton is still likely to cross swords with the industry by requiring insurance companies to sell policies to anyone who applies and by barring them from charging sick people more.
The insurance industry is likely to argue that guaranteed issue and community rating will not work unless other "cost drivers," like the cost of medical liability insurance, are addressed.
To tamp down criticism that could come from small businesses, she would not require them to provide health insurance to their workers. She would, however, provide them with a refundable tax credit to make health insurance more affordable.
There is still likely to be a contentious fight over what number of employees defines a small business.
Asked about the prospect of an employer mandate, the National Federation of Independent Businesses (NFIB) signaled its likely opposition if it were to affect its members.
"That's something that obviously we would have a problem with," said NFIB spokeswoman Stephanie Cathcart.
"We can't afford it now," she said, referring to the cost of providing health insurance. "Why would telling them that they have to provide it make it more affordable?"