Health care back as a force in presidential politics; Clinton finding her voice on the issue

~ Polls indicate health coverage ranks high with voters as a concern.

WASHINGTON -- It's been 14 years since first lady Hillary Rodham Clinton's health-care reform plan sank like a stone, swallowed by fears of a big-government power grab. In the years since, wary presidential candidates at first avoided the issue altogether, then gingerly dipped one toe, then another, back into the pool.

This year, no self-respecting presidential candidate wants to be without a health-care overhaul plan, and talk about "universal coverage" is back.

There is a stark difference between the medicine being prescribed by Democrats and Republicans.

Democratic candidates argue it is the government's job to make sure everyone has health insurance they cannot lose. Republicans are pushing more limited incentives and subsidies to help people obtain affordable coverage.

Both sides are trying to steer clear of anything resembling the 1993 plan. Clinton -- this time the candidate rather than the spouse -- comes out with her own plan Monday, adamant that "we're going to get it done this time."

Better bedside manners

Democrats in general and the New York senator in particular approach the debate this time with better bedside manners than in the last major go-around.

Even defenders of Clinton's 1993 effort to change the system say the process scared the patient -- namely, middle-income people who may want a better way, but have insurance and do not want to step into the unknown with health care.

Those fears were embodied by a middle-class couple named Harry and Louise, characters in an advertising campaign sponsored by the health insurance industry. The ads, targeting mainly opinion-makers in Washington and New York, showed the couple fretting over having to get their insurance through a new "billion-dollar bureaucracy" that would include mandatory health insurance purchasing alliances.

This time, the candidates are all "being very careful to say that, look, if you have health insurance today, you can keep it," said Kenneth Thorpe, a professor of health policy at Emory University. He has helped the top four Democrats crunch the numbers of their plans and was involved in Clinton's 1993 effort.

"The Harry and Louise ad was one of those things where people were concerned that people have to move from what they have to a plan they didn't really know." Thorpe said. "The lesson is, the less disruptive you make it, it makes it very difficult for Harry and Louise to come out and criticize it."

Already, the GOP candidates are branding Democratic proposals a step on the road to socialized medicine while they offer incremental steps such as tax breaks to expand coverage and make it more affordable.

Sticky details

"Let me tell ya, if we don't do it, the Democrats will," warns Republican Mitt Romney. "And if the Democrats do it, it'll be socialized medicine. It will be government-managed care. It'll be what's known as Hillary-care or Barack Obama-care or whatever you want to call it."

Polls indicate health coverage ranks high with voters as a concern and that people are willing to pay higher taxes to ensure those without coverage get it.

Two-thirds in a Pew poll this year supported government-financed health insurance for all. But that is absent the sticky details of how it would work or how much it would cost.

Robert Blendon, who directs the Harvard Program on Public Opinion and Health and Social Policy, said the current climate favors Democratic activism on health care but that could change quickly if the insured believe there is a threat to what they have.

"The Democrats have tried to tone it down," Blendon said, and for the most part are trying to avoid alienating insurers, physicians and hospitals. John Edwards, whose plan is the boldest among the top tier of candidates because it mandates universal coverage, has not been shy about taking on the industry.

"But I think you will find Clinton reaching out to these groups with plans that many find quite acceptable," Blendon said.

Clinton has said she wants to "figure out how we provide universal health care without putting billions more into the system." Her goal has been universal coverage in eight years.

And what might Harry and Louise think of all this?

The health insurance association that sponsored the ads has since merged into a new trade group called America's Health Insurance Plans. Chief executive Karen Ignagni strikes a conciliatory tone, saying there is greater consensus this time to move toward universal coverage -- and a better understanding of the political realities in getting there.

"We're in a different place than we were," she said. "I think that both sides are going to have to be very, very careful."

Democrats, she said, look at the Clinton-era debacle and know they have to be careful to avoid overreaching. Republicans, likewise, know they should not underreach, she said.

"The sweet spot in the middle is trying to create a workable program that individuals who currently have coverage believe is the right direction and will not cause them to lose coverage."