The debate over overhauling the health-care system is newly invigorated because the three 2008 Democratic front-runners -- Barack Obama, Hillary Rodham Clinton and John Edwards -- are making it a priority issue.
Out: Any talk of a Canadian-style single payer system. Harry and Louise, central players in the 1993 and 1994 national health-care debate. Uncertainty.
In: Cost containment. Wellness and prevention; cost-saving electronic medical records; affordable insurance premiums; limits to medical malpractice payments. Subsidies to low-income individuals to buy insurance. Working within the system. An aversion to making middle-class voters with health insurance nervous.
Harry and Louise were a fictional middle-class couple, the stars in diabolically clever ads produced by the Health Insurance Association of America designed to erode support in 1994 for the Clinton administration's ambitious plan to overhaul the health-care system in the United States. They were just a couple worried about being forced to switch doctors.
Harry and Louise were not among the nation's uninsured, today totaling 45 million. Their legacy -- which Obama, Edwards and Clinton are mindful of as they discuss their various approaches -- is that the people who have insurance, even if it is expensive and benefits parsimonious, are more powerful players in the debate over changing the health-care system than the have-nots. They are not talking about replacing the current setup with a government-run system.
Polling shows that what people care most about is that health care should be affordable, says Robert Blendon, professor of health policy and political analysis at Harvard's Kennedy School of Government, a veteran of the health-care wars of the 1990s.
Perhaps that's why Obama emphasized that the premiums people pay for health insurance would be cheaper when he unveiled his plan Tuesday at the University of Iowa. And if you have insurance and you like it, under his plan, nothing will change.
Blendon said Obama's message, -- and if I may add, that of other risk-adverse Democrats -- is that they are "trying to fix the health-care system" and "not scare a lot of middle income people."
Obama's plan -- a blend of many proposals put out by lawmakers, think tanks and states with innovative programs -- Massachusetts, California and Illinois -- is hardly radical. The signal he is sending, said Blendon, who is not associated with any presidential campaign, is "I am very much more cautious than some of you may have thought."
No matter what Clinton, Obama, Edwards or the other Democratic presidential contenders put on the table, the job of working out the details of a plan is really up to Congress, where many lawmakers will have bills in the hopper. In 1994, there were five House and Senate committees with jurisdiction over health issues working on various versions of national legislation.
One of Obama's proposals is to create a National Health Insurance Exchange to broker and oversee health insurance. One of his colleagues, Sen. Ron Wyden (D-Ore.), who has been working for months on his own plan, said in a statement, "While it's important to have minimum national standards, I'm not sure creating a new federal bureaucracy is the best approach." Wyden has a bold proposal to end the system under which most people get their health insurance through their jobs.
Then there is the matter of universal care vs. universal access.
The difference is more than a nuance. For Obama, it is a political problem because he promised a universal plan, which to people who work on health policy means some kind of a mandate to buy insurance. The Clinton and Edwards campaigns seized on the point that Obama is not mandating that everyone will have to purchase a plan.
"We expect that we will achieve virtually universal health care without that mandate," Obama told an Iowa reporter this week.
If after three to five years a sizable portion of the population was still without insurance -- say 5 percent -- then Obama said he would address "how do we make sure the last group gets into the system." Obama is working from a simple premise: more people would be covered if health insurance were affordable. But without a mandate, he leaves himself exposed by calling it a universal plan.