World and Nation

Health Care Becomes a Major Issue in Presidential Campaigns

There is no better measure of the power of the health care issue than this: Eighteen months before Election Day, presidential candidates in both parties are promising to overhaul the system and cover more — if not all — of the 44.8 million people without insurance.

Their approaches are very different, reflecting longstanding divisions between the parties on the role of government versus the private market in addressing the affordability and availability of health insurance. Republicans, by and large, promise to expand coverage by using a variety of tax incentives to empower consumers to buy it themselves, from private insurers. Conservatives warn repeatedly of Democrats edging toward the slippery slope of "government-controlled health insurance," as former Mayor Rudolph W. Giuliani of New York puts it; they instead tout the innovation and choice offered by private insurers.

The major Democratic candidates propose strengthening the private employer-based system, through which most working families get their coverage. But many Democrats also see a strong role for government, including, in some plans new requirements that individuals obtain insurance and that employers provide it, along with substantial new spending to subsidize coverage for people who cannot afford it.

Still, while they argue over solutions, both parties acknowledge the problems and their political urgency. Republicans, whose primaries usually turn on other issues, often wait until the general election campaign to roll out detailed health plans, but this time they are joining the debate far earlier.

Democrats are competing among themselves over who has the bigger, better plan to control costs and to approach universal coverage — a striking change from the party's wariness on the issue a decade ago after the collapse of the Bill Clinton administration's health care initiative.

And both parties are closely monitoring developments in the states as potential blueprints for a centrist compromise, especially in Massachusetts, which recently began a major plan aimed at requiring every individual to have insurance.

In short, said Jonathan Gruber, an economist, health expert and Clinton administration veteran, the times are "radically different."