Amidst all the hype over his meteoric rise to the top rungs of the Democratic Presidential field, Barack Obama has been especially criticized for running a campaign that is long on high-flown rhetoric and short on policy specifics. On Tuesday, in Iowa, he tried to address that potential weakness in a dramatic way. Taking on one of the nation's most urgent and politically fraught domestic challenges, Obama unveiled a detailed health care proposal that he claims would come close to providing health coverage for the 45 million Americans who now lack it, while reducing health care costs of the typical American family by as much as $2,500 a year. The plan, which the Illinois Senator vowed to implement by the end of his first term in the White House, would cost the government an additional $50-$65 billion a year, which Obama said he would pay for by allowing President Bush's tax cuts for those making over $250,000 a year to expire.
Obama's plan contains many of the features of the failed health care proposal pushed more than a decade ago by his rival, Hillary Clinton, that went down in flames in 1994, including its most controversial element: a legal mandate that employers provide coverage for their workers, or pay a percentage of their payroll into a fund for the uninsured. But he insisted that the political climate around the issue has changed dramatically since then, and that businesses are far more open to the idea. "Rising costs have caused many more businesses to back reform," he said in a speech at the University of Iowa Hospital in Iowa City, "and in states from Massachusetts to California, Democratic and Republican governors and legislatures have been way ahead of Washington in passing increasingly bolder intitiatives to cover the uninsured and cut costs."
Obama also borrows from a major cost-cutting proposal that John Kerry put forward in his 2004 Presidential campaign, in which the government would pay part of the cost for covering catastrophic illnesses like cancer and heart disease that require the most expensive treatments and surgeries, which consume a disproportionate share of the nation's total health care tab. And as with a number of other reform proposals, including one by his Presidential rival John Edwards, Obama would set up a health insurance program similar to that now offered to federal employees, where the uninsured could pick among a group of plans, with subsidies provided to those who could not afford to buy in. But one idea that Obama rejected is a so-called "individual mandate," similar to that being tried in Massachusetts and proposed in California, where everyone would be required to buy health insurance, just as car owners are now required to carry auto insurance.
In truth, Obama's plan could fall somewhat short of real "universal coverage." It would exempt the smallest businesses from the requirement that they cover their workers. (The exact size of the exemption has yet to be determined, but one campaign official said it would apply to businesses employing "some number less than 15.") And while it would require coverage of children, adults could choose not to take advantage of his plan and go uninsured, even if they could afford coverage.
The Illinois Senator also promised that his plan would pour billions into upgrading medical record-keeping, make hospitals collect and publicly report measures of their own health care quality, and require more generous coverage of preventive care. He also said he would put new emphasis on personal responsibility in health care, although giving back some ammuniton to his critics he didn't specify how he would do it. "In the end," he said, "prevention only works if we take responsibility for our own health and make the right decisions in our own lives if we eat the right foods, and stay active, and listen to our wives when they tell us to stop smoking." That last reference drew a knowing chuckle from his audience, where many were familiar with Obama's own struggle to kick his nicotine habit.
Elements of his plan are certain to draw opposition from the increasingly concentrated insurance industry. The most controversial would limit their profits in areas of the country where health insurance is provided by just a few carriers. "We'll investigate and prosecute the monopolization of the insurance industry," Obama said. "And where we do find places where insurance companies aren't competitive, we will make them pay a reasonable share of their profits on the patients they should be caring for in the first place." Strong words, but Obama may yet find out that, on that particular proposal, he is being too specific for his own good.