Clinton vs. Obama: dueling health plans

SUMMARY: Clinton says Obama leaves 15-million uncovered; he calls his plan "universal." Who's right?

With the Democratic primary field in a tight race going into a recent debate in Las Vegas, Hillary Clinton attacked her two main rivals. She chided John Edwards for being a convert to universal health care (we checked that claim here ) and she criticized Barack Obama for a plan that she said doesn’t include universal coverage.

Obama "talks a lot about stepping up and taking responsibility and taking strong positions," Clinton said, "But when it came time to step up and decide whether or not he would support universal health care coverage, he chose not to do that. His plan would leave 15-million Americans out."

Obama shot back: "Well, let’s talk about health care right now because the fact of the matter is that I do provide universal health care. The only difference between Sen. Clinton’s health care plan and mine is that she thinks the problem for people without health care is that nobody has mandated — forced — them to get health care."

Before jumping into this fray, it’s important to note that when it comes to health care, these Democratic presidential candidates have a lot in common.

All leave in place employer-based private insurance. All increase eligibility for the poor and children to enroll in initiatives like Medicaid and the State Children’s Health Insurance Program. All subsidize premiums for some employers; and all create pools for individuals to buy their own cheaper insurance. Initiatives to increase technology and use more preventative care will lower costs, according to these plans.

One of the few differences is that Clinton and Edwards include a universal mandate. That means that after everything else goes according to plan, individuals will be required by law to purchase insurance. Think of how people are required to buy auto insurance and you get an idea of what that might look like.

A mandate achieves several goals: It makes sure that most people have insurance, it gets healthy people to participate, and it encourages preventative care. Anyone who doesn’t buy insurance could be considered a lawbreaker and be fined.

Obama’s plan includes a mandate to insure children, but it does not include a mandate for adults, as the Clinton and Edwards plans do. That likely means not as many people will be insured, said Kenneth Thorpe, professor of health policy and management at Emory University.

"Clinton’s plan will cover more than Obama’s because that’s the nature of a mandate. I think he understands that because he does mandate coverage for kids," Thorpe said.

Obama’s decision not to include a mandate is a more cautious approach, one Obama says is designed not to penalize people with modest incomes. If premiums don’t drop enough after all the reforms are implemented, people will still be unable to afford insurance. If a law mandates they buy it anyway, they probably won’t. Obama’s argument is that if you then fine them, you’re essentially punishing the poor — and they will still be uninsured. Obama is betting that his plan will get costs low enough that many of the estimated 47-million uninsured will sign up without a mandate, and a mandate will come later.

As we heard during the debate, Clinton believes 15-million people would be left uncovered by Obama’s plan. She based her analysis on an article written by Jonathan Cohn of the New Republic, who quoted RAND, the Urban Institute and MIT economist Jonathan Gruber.

Realistically, though, the claim is an educated guess. Given that 47-million people are uninsured now, 15-million uninsured after Obama’s plan doesn’t seem unreasonable, according to several experts — it would mean that Obama succeeded in covering almost 70 percent of those currently uninsured. But neither Clinton nor Obama offer hard numbers on what income levels would qualify for what programs. Some experts believe the plans don't offer enough detail to create a reliable estimate for such a complex issue.

Finally, Clinton’s attack on Obama about the mandate ignores another unknown: how many people will defy a mandate and remain uninsured.

Most health experts are watching Massachusetts, which recently passed a health plan that includes a statewide mandate. (The plan was passed under then governor, now presidential candidate, Mitt Romney.) Residents have until the end of 2007 to buy their own insurance or lose a tax deduction. According to initial press reports, what’s happening is that some people are willing to be fined rather than buy insurance they either don’t want or can’t afford. Some will qualify for an exemption and remain uninsured without penalty; others will not sign up and take a tax hit. Officials and health care experts are waiting to see how many people defy the mandate.

If many people in Massachusetts remain uninsured, that would bolster Obama’s claim that prices need to come down before a mandate is reasonable.

The argument over the mandate may go on for some time, if polls of primary voters are an indication. For Democratic primary voters, universal coverage is the most important health care issue, according to Robert Blendon, a professor of health policy and politics at Harvard School of Public Health. Republicans, on the other hand, are more concerned about costs and efficiency, he said.

"That’s why this small wedge with Obama is getting to be more important," Blendon said.

So is it fair for Obama to call his plan "universal"? Well, not really. Even if you buy his argument that his plan will create the market conditions to make health care universally available, nothing in his plan guarantees it. We rate his claim Barely True.

Clinton is accurately quoting the studies that estimate how many will be uninsured under Obama's plan. But other experts question the validity of a hard number, given the limited data. It's a tough call, but because of the disagreements here, we find her claim to be based on too many hypotheticals to rate more than a Half True.