Health care waits to ignite as campaign issue

DENVER (Reuters) - The sharply contrasting health care visions of Republican John McCain and his Democratic presidential rivals offer the promise of a grand campaign debate -- if the candidates find room on a crowded agenda.

While health care reform ranks as the second-biggest domestic issue after the economy in most national opinion polls, it will compete with the Iraq war, taxes, high gas prices and other topics for a prime-time spot in the campaign for November's presidential election.

Nearly two decades of health care debate has made little headway toward finding a consensus approach, and the issue has not been a key factor in a presidential election since the collapse of the Hillary Clinton-led reform effort in 1994.

"There is no question there are fundamental, Grand Canyon-like differences on health care between the two parties," said Drew Altman, president of the Kaiser Family Foundation, a nonpartisan health policy group.

"But it's an open question whether it will be a hot issue in the campaign," he said. "I now believe the biggest obstacle to health care reform is this ideological divide -- is there any way to bridge these differences?"

McCain, who has clinched the Republican presidential nomination, and Democratic Sens. Barack Obama of Illinois and Clinton of New York have unveiled ambitious but very different plans to overhaul the health care system.

McCain finished a week-long campaign swing in Denver on Friday that highlighted his plan, which would use tax credits to help shift from employer-based insurance coverage to an open market system where people can choose from competing policies.

Clinton and Obama seek universal health coverage for the 47 million Americans without insurance. Clinton would mandate coverage, while Obama would require it only for children.

The Democratic plans would keep the existing job-based insurance system but expand government involvement in a hybrid public-private system.

TOUGH SELL

McCain calls the Democratic plan a "big government" solution that limits choice. Democrats say his plan reduces the incentive for companies to offer coverage and puts workers at risk of not getting it -- particularly those with pre-existing conditions that insurance companies will not cover.

Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan policy research organization, said the Democratic plans had more political appeal.

"I would expect to see the Democratic approach resonate more with voters. They are very clearly telling voters you are going to be eligible for a public program," he said.

McCain's plan to allow people to move away from job-based coverage is a tough sell, analysts said. Polls show three-quarters or more of Americans are generally happy with the insurance they get through their employers.

At least some of the political fury that doomed Clinton's health care initiative in 1994, when she was first lady, was fueled by the reluctance of people to abandon their employer health coverage.

A 2007 survey by the Commonwealth Fund, a private nonpartisan foundation that supports health policy research, found four of every five Americans, including three-quarters of Republicans, believed employers should either provide health insurance for workers or contribute to the cost.

"People are comfortable with what they know and afraid of change," Altman said. "The burden of proof is always on people who want to change their current health plan."

McCain's plan is similar to the one put forth by President George W. Bush that fell flat in Congress, where gridlock on the issue is the norm. All of the proposals would face potentially drastic changes in Congress.

'BASIC INSECURITIES'

"I don't think McCain's plan goes to the heart of people's concerns. It does not address the basic insecurities of not having coverage or not having enough money to pay your bills," said Susan Davis, president of the Commonwealth Fund.

"It may sound good. 'You're in charge.' But because of the way the insurance market works, it's difficult," Davis said. "The whole market is geared to excluding people who are sick."

McCain said Americans would warm to his proposals once they became familiar with them.

"I'm confident that when we debate and discuss this issue most Americans would rather have their families making decisions about their health care," McCain told reporters last week. "The issue cannot go unaddressed."

But Ginsburg did not sound confident health care would become a top agenda item in the next six months.

"I wonder if it's going to be so complicated that people tune out," he said. "We probably won't come out of this election with a real mandate for getting it done."

(Editing by Xavier Briand)

(To read more about the U.S. political campaign, visit Reuters "Tales from the Trail: 2008" online at http:/blogs.reuters.com/trail08/)