By Marilyn Werber Serafini and James A. Barnes, National Journal
© National Journal Group Inc.
Friday, July 18, 2003

"A flawed, trillion-dollar plan that will cost the American people even more in the long run." That's how Vice President Gore described the comprehensive health care proposal of his opponent, former Sen. Bill Bradley of New Jersey, during the 2000 Democratic presidential primaries. Gore had a few other choice words for the Bradley plan -- words like "ludicrous" and "disaster."

How far do the 2004 candidates' health plans go toward solving pressing problems? Our expert panel grades them.

But today, several of the Democratic Party's White House hopefuls are putting forward health care plans that are so pricey they would make Bradley's more modest proposal blush. The plan offered by Rep. Dick Gephardt of Missouri, who endorsed Gore in 2000, would cost the Treasury more than double the tab for the Bradley plan.

Former Vermont Gov. Howard Dean, who is a physician, endorsed Gore in 2000 and specifically cited Gore's less ambitious proposals for expanding health insurance coverage as a reason for his decision. "I favor the incremental approach," Dean said at the time, according to the Associated Press. "It's not as big. It's not as sexy. But it works."

Candidates' Grades On... The Uninsured Patients' Costs Government Spending Quality Of Services Malpractice Rates Related Resources On NationalJournal.com Latest Polling On Health Care · Q&A With Barbara Kennelly, Chairwoman Of National Committee to Preserve Social Security and Medicare · Book Review: "From Chaos To Care: The Promise Of Team-Based Medicine" · Book Review By Former Vermont Gov. Howard Dean: "Severed Trust: Why American Medicine Hasn't Been Fixed" · Daybook: Upcoming Health Care Related Events Additional Information On The Web Kaiser Family Foundation Section On The Uninsured · Alliance For Health Reform Report On People Without Health Insurance (PDF) · Op-ed By Harvard Professor Robert Blendon About Voter Concern Over Health Care After The 2002 Midterm Elections · Recent Congressional Budget Office Report On The Uninsured (PDF) · Galen Institute Article On Using Federal Tax Credits To Help The Uninsured · Heritage Foundation Report On President Bush's Health Care Plan · Health Care Proposals By Braun, Dean, Gephardt, Kerry And Kucinich

Today, Dean is advocating health care initiatives that would extend insurance to significantly more Americans than Gore sought to cover. And Dean would do so at a cost that is more than double what the former vice president was willing to spend.

What's going on here?

For starters, the problems of the nation's health care system have continued to worsen. The number of uninsured Americans keeps climbing, as do the out-of-pocket expenses of workers who are covered through their employers' plans. Some small businesses are seeing their health insurance costs jump 20 to 30 percent a year. And employees are facing sizable increases in premiums, deductibles, and co-payments, and in the costs of treatments and some expensive drugs that insurance plans don't cover.

The spread of managed care programs slowed the increase in health care costs in the early to mid-1990s. But costs are once again rising through the roof. And the highest unemployment rate in a decade has many Americans fearful that if they lose their job, they will no longer be able to afford health insurance.

"The problems are getting bigger, and costs of solving them are getter higher," said Diane Rowland, executive vice president of the Henry J. Kaiser Family Foundation, the nation's leading health care nonprofit. "The time is right to say that if you fix the problem, you have to do it in a comprehensive way."

Many of the 2004 Democratic presidential candidates seem to agree with that assessment. Two -- Rep. Dennis Kucinich of Ohio and former Sen. Carol Moseley Braun of Illinois -- propose a universal, Medicare-style, single-payer plan for everyone in the nation. And Gephardt would provide tax credits to businesses to subsidize insurance coverage for all American workers. Other candidates, including Dean and Sen. John Kerry of Massachusetts, have offered a patchwork of new or expanded government programs to extend coverage to many, but not all, of the uninsured.

The hodgepodge of Democratic plans and price tags is no doubt a blur even for voters who are trying to pay close attention to the presidential candidates' positions at this early stage in the contest. "Right now, it doesn't look like voters can tell the differences in [candidates'] plans," said Democratic pollster Celinda Lake.

To get a better sense of how the various health care proposals compare with one another and with the views of President Bush, National Journal asked 10 health policy experts to assess how far the Democratic plans and Bush initiatives would go toward achieving a number of widely shared goals -- ranging from thinning the ranks of the uninsured to holding down spending, improving the quality of care, and encouraging doctors to remain in the profession.

Over the course of the 2004 campaign, the Democratic candidates are likely to keep the focus on health care. Many party activists complain that their congressional leaders were too timid last year in drawing policy distinctions with the White House. And health care presents the party's presidential contenders with a clear opportunity to differentiate themselves -- from one another and from the Republican incumbent.

"People are looking for an important issue where there are real differences," said Andrew L. Stern, the president of the Service Employees International Union, which counts many health care workers among its members. "For the moment, I'd say [health care] is No. 1."

Primary Politics
This spring, Gephardt aggressively seized the initiative on health care by unveiling the huge, creative insurance proposal that is now a cornerstone of his presidential campaign. His plan to provide tax credits to businesses to subsidize the coverage of all employees is one of the most far-reaching and expensive ideas of the campaign so far.

In talking about his plan, Gephardt never fails to personalize the issue by describing the medical crisis his family faced when his son, Matt, was diagnosed with cancer as a child. Fortunately, the St. Louis law firm where Gephardt worked provided health insurance that allowed Matt to have an experimental treatment, which proved successful. Gephardt declares that no parent should have to let a child's life-threatening illness go untreated because of a lack of insurance.

By offering his bold plan, Gephardt has recast himself -- from the cautious congressional leader who failed to win back the House for his party to a presidential candidate unafraid to think big. "The health care plan was the spark that relit a lot of his labor support," said SEIU's Stern. Indeed, Gephardt has collected a handful of early union endorsements -- including, on July 11, that of the politically influential International Association of Machinists and Aerospace Workers.

"He's made a big political gamble that he can ride the health care issue to the White House," Stern said. "When he was [the House Democratic] leader, he didn't have a bold health care plan, and now he's gotten way out there."

Although Gephardt's plan has won kudos from many liberal Democrats, it's a mighty big target for his rivals, who say the government has better ways to spend money than by giving tax credits to employers already offering health insurance.

Earlier this year, as he was developing his ambitious plan, Gephardt said he hoped to keep the 2001 Bush tax cuts that provided relief to lower- and middle-income Americans -- expansion of the child tax credit and elimination of the so-called marriage penalty, for example. But his health care proposal's price tag is so large -- $212 billion in the first year alone -- that Gephardt now calls for repealing all of the Bush tax cuts, not just the breaks for the wealthy.

As a result, some Democrats fear that if Gephardt became their presidential nominee, Bush would be able to tag him as just another tax-and-spend Democrat. "A candidate who is counting on money from suspending tax cuts for the middle class will face an enormous burden of proof," said Bruce Reed, president of the Democratic Leadership Council, the party's leading centrist organization. That's what will kill "Gephardt's health plan: If it depends on additional [tax] dollars from working- and middle-class families, he's not going to win that argument."

But Gephardt may benefit from Americans' skepticism about how much tax relief they actually get, even from massive tax cuts. As the Missouri congressman told reporters last spring in comparing his health care package with the less-expensive plans touted by Dean and Kerry, "I want to put a real choice in front of people. And I'm willing to say to people, 'If you like the Bush tax cut, if you think you've really benefited from this, and this is the best thing, then vote for Bush. If you want to have guaranteed health care coverage that is affordable and can't be taken away, then come with us.' "

Gephardt also frequently hears the charge that giving businesses bigger tax breaks to keep doing something they are already doing doesn't make financial sense.

"It's spending billions on corporations that are already doing this, with no gain in terms of added people who are covered, and is a huge inflow of government funds to those companies," said Dean's campaign manager, Joe Trippi.

"Shouldn't we spend this money on education, prescription drugs, homeland security, and incentives that would actually create new jobs?" asked an adviser to Sen. Joe Lieberman of Connecticut, who is still developing his own health care plan.

Gephardt counters that one of the problems with the Clinton administration health plan that died in 1994 was that it placed new demands on employers even if they already provided health insurance. "So it was seen as unfair," Gephardt told reporters. "I try to deal with everybody in an equal and fair way."

And that, Gephardt maintains, is one reason he could get his plan through Congress. "It's universal. It is simple. It is bold. And it solves the problem for everybody," he declared last spring. "I think that's what you have to do to get the political backing and the political support that you need to pass this plan."

Dean is one Democratic candidate who won't be stressing the legislative arts in promoting his health care plan. In Trippi's view, because Dean is a doctor and had some success as governor in extending health coverage to every child in his state, he will stand out when primary voters make their way through the maze of plans offered by the Democratic hopefuls.

"You can end up with six plans that policy experts will say there's an upside and downside to. And what people want to know is what credibility you have," Trippi added. "People connect with Dean because he's a doctor and there's a record of progress in Vermont, versus a member of Congress or the Senate who has a plan, but we've heard it all before and it's never been implemented."

Dean, who showcases his record of balanced budgets in Vermont, says he would spend an additional $90 billion a year on health care, an amount that's not likely to raise much concern among Democratic primary voters. Unlike 1999 when Bradley was proposing his big health care initiative, today, Democratic candidates are not constrained by a Democratic president touting a balanced federal budget. And since Bush has spent much of the once-projected surplus on tax cuts, Democratic primary voters won't expect their candidates to restrain themselves on the spending side.

"I'm not sure attacking a health care plan for being too generous in a Democratic primary works," said Democratic media consultant Anita Dunn, who advised Bradley in 2000. She thinks cost might become "a bigger issue" in the general election, but adds that voters are now more receptive to muscular solutions. "The [health care] problem has come back into the public mind in a very, very real pocketbook way," Dunn said. "It is where so much of the economic insecurity is focused, in the way that it wasn't five years ago."

Republican pollster Bill McInturff thinks that because the Democratic race is focused on health care, Bush will be forced to offer new ideas about how to cover uninsured Americans and curb the rise in health care costs. "That question is now part of the 2004 campaign, and that question is now going to have to have an answer," McInturff said. He added that Bush and his advisers need to merge his various initiatives "into some coherent way of telling people that we have an approach to health care."

Voters tend to give the Democratic Party the edge on health care issues. But Democratic candidates need to tread carefully, because Democratic voters' views on health care are somewhat different from those of the nation as a whole. While likely Democratic primary voters are equally concerned about the growing ranks of the uninsured and about rising costs, according to Democratic pollster Lake, general election voters -- by more than 2-to-1 -- are more concerned about costs.

"To a primary [election] audience, you can talk about removing the tax cut to pay for providing access for the uninsured," Lake said. "In the general election, if that's the only dialogue you're having, it sounds like you're for increasing my taxes [to pay] for the uninsured, and what are you doing for me?"

Rating The Plans
National Journal asked 10 health care specialists to assess the various presidential candidates' health plans. After consulting those and other health policy experts, we created a rating system for judging how well each plan addresses five of the most pressing problems confronting the nation's health care system: the uninsured, consumer spending, government spending, quality of care, and whether care is financially and geographically accessible to patients. Although some candidates have offered prescription drug proposals, we avoided that topic because congressional action might soon alter candidates' positions.

National Journal's 10-member panel agreed to give each candidate a series of numerical grades from 1 to 5, with 5 being the best rating. The group included conservative, liberal, and nonideological experts, mostly from research and educational organizations. We averaged each candidate's marks in a given category to produce a final score. We gave candidates an overall score in a category only if at least eight judges considered a candidate's proposal fully formed enough to be assessed.

The 10 judges were Robert Blendon, professor of health policy and political analysis at Harvard University's School of Public Health; Paul Fronstin, senior research associate at the Employee Benefit Research Institute, a nonprofit, nonpartisan policy research organization; Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan policy research organization; John Goodman, president of the National Center for Policy Analysis, a conservative think tank based in Dallas; Ed Haislmaier, visiting research fellow at the Heritage Foundation, a conservative think tank; Ed Howard, executive vice president of the Alliance for Health Reform, a nonpartisan health care education organization; Chris Jennings, White House health care policy adviser to President Clinton and now president of Jennings Policy Strategies, a health care policy consulting firm; Jack Meyer, president of the Economic and Social Research Institute, a nonprofit, nonpartisan research organization; Robert Reischauer, former director of the Congressional Budget Office and now president of the Urban Institute, a left-leaning think tank; and Gail Wilensky, administrator of the Health Care Financing Administration (now the Center for Medicare and Medicaid Services) under President George H.W. Bush and now a senior fellow at Project HOPE, a health care policy education foundation.

The survey questions were crafted to elicit objective assessments, not political or policy views. Regarding the uninsured, for example, National Journal asked how close each proposal would come to seeing that all Americans have health insurance. We did not want answers that reflected the judges' political leanings or personal views about whether a given plan was the best -- or even a good -- approach. Judges' scores were remarkably consistent. Both liberal and conservative judges gave Gephardt high marks for aiming to extend insurance coverage to at least 97 percent of Americans, even though some judges oppose Gephardt's reliance on generous new employer subsidies -- and a universal employer mandate -- to accomplish his goal.

On the question of whether a given proposal would increase government spending beyond current obligations, conservatives and liberals alike gave Bush high marks because the price tag for his approach, $89 billion over 10 years, is by far the lowest of the lot. Some of the judges, however, support significantly higher spending.

Because three candidates -- Sen. John Edwards of North Carolina, Sen. Bob Graham of Florida, and Lieberman -- had not released full health care proposals at the time of the survey, and because others hadn't addressed certain issues, some candidates' ratings are incomplete. (The Rev. Al Sharpton has talked little about health care and could not be rated.)

Starting with the uninsured, National Journal examines how the presidential candidates' health plans fared when judged on five key criteria.

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