Health-care fix looms large over 2008 races

By Joanne Kenen

WASHINGTON (Reuters) - Health care could undergo its biggest revolution in decades under the proposals of presidential hopefuls trying to fix a system that has left one in seven Americans without insurance.

No other major industrial democracy has such a large number of people without health coverage.

Opinion polls have shown health care to be the top domestic issue for Democrats. At least one survey found that Democrats ranked it as important as Iraq. Republican voters also are paying more attention than in past years.

Democratic candidates are proposing universal health coverage through a mix of public and private plans. Republicans say they will make insurance cheaper and more accessible through tax and market changes that may speed up the shift away from an employer-based system.

"This will be the broadest philosophical debate we've had about health care in a long time," said Robert Blendon, an expert on health politics and policy at Harvard's Kennedy School of Government.

Candidates are churning out health plans that are unusually detailed for this point in a campaign, although none are likely to become law without significant evolution, compromise and input from Congress.

Even that may not be enough. The country has wrestled with health coverage off and on for decades without consensus.

The two main parties have deep and defining differences.

While the major Democratic candidates differ on details, they say they are committed to universal coverage. They aren't proposing a government-run health plan, but they do foresee an expanded role for Washington in a hybrid public-private system.

"HEAVY-HANDED"

"It's heavy-handed," Robert Moffit, a policy analyst at the conservative Heritage Foundation, said of the approach outlined by New York Sen. Hillary Clinton and the other Democrats. "There would be a massive shift in regulatory authority over health from the states to the federal government."

Republicans don't promise "universal coverage" but "universal access." Not all the Republicans have yet released detailed plans but they speak of market reforms and tax breaks to make insurance more affordable.

Some also advocate "consumer-directed" health care and tax-favored health savings accounts to stimulate savvier health spending and "personal responsibility."

Democrats' plans may have bigger price tags but some experts see the Republican approach as representing a more dramatic break with the past.

"It gets all confused in the rhetoric but the Republicans represent a more radical change by moving away from the employer-based system to tax breaks and the individual insurance market," Drew Altman, president of the nonpartisan Kaiser Family Foundation, said in a recent interview. "But I don't think that thought has crystallized at all for the public."