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Details, Details

Clinton and Obama should get specific on health care

Last month the Service Employees International Union (SEIU) issued an ultimatum to the Democrats running for president: Issue detailed plans for universal health care by August 1. Or else.

OK, it wasn't quite that dramatic. There was no threat of specific reprisals against candidates who fail to meet the deadline. Nor was there a precise definition as to what would qualify as "detailed." Given that the SEIU's president, Andy Stern, has been willing to embrace companies like Wal-Mart for making the vaguest of commitments to universal health care, it's safe to assume Democratic candidates could satisfy the union's demands without getting too specific.

But that doesn't mean vague is good. Indeed, with health care atop the domestic political agenda, the Democratic candidates need to flesh out their visions for how they will make health care affordable for everybody--even though it means facing some potential political hazards.

Getting specific isn't such a problem for Senator John Edwards, who earlier this year unveiled an ambitious framework for universal coverage. But it does present a quandary for the two frontrunners, Senators Hillary Clinton and Barack Obama. While both have promised that they would pursue universal health care as president, neither has said much about how they would achieve this.

This reticence doesn't reflect lack of interest. Both candidates have histories of working on the issue--Clinton, most famously, when she ran the task force that developed her husband's ill-fated universal coverage proposal in 1993. And both candidates seem sincere in their desire to overhaul American health care so that citizens here finally share the kind of financial and health security that citizens in the rest of the developed world have long enjoyed.

No, the reason Clinton and Obama are acting so cautiously is that they fear getting specific on health care will expose them to political attacks--the kind that could doom their candidacies and the prospects for universal coverage simultaneously. It's a powerful argument that goes something like this: As soon as a candidate explains exactly what he wants to do about health care, he becomes a piñata for his rivals and--eventually--special interests, who can be counted on to seize on the provisions that are most unappealing politically, even if it means twisting what they mean.

The case study in this was the campaign for the Democratic presidential nomination in 2000, when then-Senator Bill Bradley put forth an ambitious proposal that would have brought coverage to about half the uninsured population. Then-Vice President Al Gore tore it apart--claiming, among other things, that Bradley's plan would leave the poor worse off than now. Nobody following the debate seriously, or familiar with Bradley's record in office, believed that would actually happen. But Gore's attacks were instrumental in blunting Bradley's initial momentum--and, eventually, depriving him of victory in the New Hampshire primary.

Howard Dean had a similar experience in 2004. He put forth what was arguably the most fiscally realistic plan for expanding insurance coverage to nearly all Americans, offering to pay for the proposal by rolling back Bush's tax breaks. But he rarely got credit for it. Most pundits, unfamiliar with the details, ended up parroting the talking points of rival camps. A few actually called Dean's plan fiscally irresponsible.

And all of that was just in the primaries. Any plan to give all Americans health insurance is going to involve more government (since only government can subsidize the poor and provide coverage to people whose medical conditions make them uninsurable in the private market). And it's also going to involve higher taxes (since the government can't do these things without more money). Democratic primary voters tend to be tolerant of such things. But swing voters? Not so much. A candidate committing himself to these propositions would seem to be inviting a lot of hostility from the voters who determine election outcomes.

Today, virtually any Democratic candidate proposing universal coverage can expect such treatment. But Clinton and Obama come into the contest with additional liabilities. As Clinton herself says, she has the scars from the fight to create universal coverage in 1994. (Whether she deserves those scars is another story.) And she's still dogged by the perception that she's too liberal and uncompromising to be president. She's worked hard to dispel that image, but coming up with a firm set of principles on health care reform would surely invite accusations that she's back to her old and supposedly evil ways.

Obama has a different problem. He has enjoyed a meteoric rise, but a lot of that success reflects his ability to speak in broad, inspiring terms about unity and shared purpose. A realistic health care plan is bound to upset at least some interest groups--and to create some losers, even among voters. In other words, it's bound to offend.

These liabilities, however, are precisely why we need to hear more from Clinton and Obama--whatever the risks. The great reservation many liberals have about Clinton is whether her experience as First Lady has made her too gun-shy--whether she's too stuck in the mindset of the late-'90s, when triangulation was necessary for political survival, to stretch the boundaries of debate enough to make universal coverage possible. The great doubt about Obama, meanwhile, is whether all that rhetoric about shared purpose and common ground precludes him from taking strong stands that, inevitably, provoke strong opposition.

The question about both candidates, in other words, is whether they are willing to pick fights. And when it comes to health care, certainly, it matters just as much which fights they want to pick. In theory, there are a lot of ways to achieve universal coverage. In practice, some work better than others. (And some don't work at all.) So it's important to know the answer to some basic questions: What role do the candidates see for private insurance? Whose taxes will they raise--and how much can they offset the financing by eliminating waste? What level of benefits do they consider adequate? If there are trade-offs between access, cost, and quality, where are they willing to make sacrifices?

Without a doubt, answering these questions means risking political attacks. But there is also much to gain. As Yale political scientist Jacob Hacker has noted, while Republicans expect their candidates to talk tough, Democrats expect their candidates to sound like policy wonks. And, even though it's early in the campaign, there's actually little reason to believe that releasing detailed proposals sooner rather than later would make Clinton and Obama more vulnerable.

Take a closer look at what happened to Bill Clinton in 1994. It's true that the plan was ripped apart by Republicans and special interests that opposed it. But that all happened after he became president, when the legislative process began. During the presidential campaign itself, Clinton almost certainly benefited from talking specifics. Voters didn't necessarily understand exactly what he wanted to do. But his willingness to be specific helped convinced voters that he wanted to do something. It also signaled that he had a sophisticated grasp of government--something people might otherwise have doubted, given that this prior experience was as the governor of a small state.

As for Bradley--the other episode that spooks so many Democratic health care reform advocates--his failure to overcome criticism of his plan had less to do with what he was proposing and more to do with the fact that his campaign simply hadn't fully prepared to defend itself. Bradley wanted to take the high road; as a result, the campaign waited days before crafting and putting out responses. By then, the damage was done. With a little foresight, Clinton and Obama can easily avoid making such a mistake this time around.

There's one more good reason Obama and Hillary Clinton should say more about health care, quite apart from what it might or might not do during the campaign: It will help them actually pass a plan, by building a mandate for even those aspects of universal coverage that seem unappealing at first glance.

After all, while the case for universal health care is persuasive, it is also complicated and treacherous. It will take time to convince voters that more government and more taxes will actually make most people better off financially, while giving them something they now lack: guaranteed health security. (Not to mention simplicity, a more competitive economy, and so on.) If the candidates start talking that way now, they have a much better chance of winning that battle after January 2009. To his great credit, John Edwards has been doing just that as he explains his plan on the stump. Now Clinton and Obama need to show us that they can do the same thing.