With his recent speech on healthcare, Bill Bradley
has moved the worsening plight of the uninsured back into the spotlight. In doing so, he
has offered a challenge not only to his main presidential rivals, Al Gore and George W.
Bush, but also to a nation too long resigned to accepting the uninsured as an indelible
stain on the civic fabric of America.
Just a few years ago, this challenge seemed improbable. After Clinton's complex health
plan died in 1994, the best many health reformers hoped for were timid incremental changes
that offended few and accomplished little. Since then, however, the growth of medical
spending has slowed, making cost containment less pressing. At the same time, roughly a
million Americans a year are being added to the ranks of the 44.3 million uninsured, as
employers scale back coverage and welfare recipients take low-wage jobs. In George W.
Bush's Texas, for example, about a quarter of residents are uninsured-the highest share in
That this erosion of coverage is occurring at a time of remarkable prosperity makes it
all the more troubling. Yet it has also made the problem newly attractive as a target of
public action. President Clinton's plan, constructed in the harsh budgetary climate of
1993, was basically a zero-sum proposition in which tough new regulations and mandates
would permit expanded benefits and coverage. The proposals considered today are mostly
about showering more money and more tax favors on our already heavily subsidized
Bradley's new proposal moves away from this post-Clinton-plan consensus- but only so
far. The aims are undeniably lofty: universal coverage for children, near-universal
coverage for adults, along with smaller improvements in Medicare. And the proposal carries
a hefty price: an estimated $ 65 billion a year, which Bradley says would come from the
projected federal budget surplus. The means are varied and sometimes innovative: Parents
would be "responsible" for obtaining insurance for kids (Bradley has not
specified an enforcement mechanism). Tax credits for health insurance would be made
available on a sliding scale, with premiums fully paid for those in lower income brackets.
And all Americans would be able to buy into the same plan that provides private health
insurance to federal workers, including members of Congress.
Yet the Bradley proposal promises the candy without the bitter medicine. Bradley wants
the government to underwrite private insurance for those without it, but he is
understandably reluctant to explain how private plans would be kept affordable and secure
when premiums rise, employers shed coverage and insurers cherry-pick the healthy. This may
be shrewd politics, but it is shaky policy. Under the Bradley proposal, the federal plan
would likely attract high-cost patients as employers dump coverage and health plans price
the unhealthy out of the market. Without a strict requirement that children be insured,
many would likely remain uncovered. And if more or sicker people join the federal plan-or
if, as expected, premiums spike upward-the expenditures of the program would likely outrun
expected surpluses, whose size remains uncertain in any case.
Still, these complaints should not obscure what is valuable in Bradley's vision. Most
compelling is his commitment to universal coverage for children-a goal he correctly likens
to the original aim of Medicare, which also targeted a sympathetic population ill served
by employment- based insurance. Yet Bradley might have taken the Medicare analogy further.
Like others who advocate children's insurance, he wishes to insert a new system of
subsidies and government-supported insurance into the existing patchwork of
employment-based coverage. This makes little sense. Corporations would continue to drop
coverage even faster if subsidized plans existed, and millions of children would
inevitably fall through the cracks, as millions do today. (Last year the number of
uninsured kids increased by 330,000, to 11.1 million.) A single federal program in which
all Americans would be enrolled from birth until 18- Medicare for kids-would be the most
effective and courageous way to uphold Medicare's legacy.
But Bradley's proposal at once allies him with a noble cause and separates him from
Gore and Bush. Although Gore has also vowed to assist the uninsured, his proposal is more
modest, promising neither to achieve universal coverage nor to provide
government-sponsored insurance. Gore's main idea is to expand the scattered state programs
for children funded by the 1997 budget deal-which to date have managed to cover only a
pitiful proportion of uninsured kids. Bush has distinguished himself mainly by trying to
limit the expansion of children's coverage. When the Texas legislature considered how to
spend the new federal money authorized in 1997, Bush fought to cover only kids in families
with incomes below 150 percent of the poverty level, rather than the 200 percent that
other states had adopted and that the legislature eventually enacted.
No one should be sanguine about the prospects for meaningful reform, but perhaps we
will someday look back on the fragmented initiatives of the late nineties as an early,
halting step toward a broader commitment of the kind that Medicare represents. If so,
Bradley will deserve a share of the credit. With his proposal, he has helped restart a
debate that is necessary and overdue. As Bradley expressed the sentiment in his speech,
"It is time to try again-but in a different way."
Jacob S. Hacker, a fellow at the New America Foundation and a junior fellow of the
Harvard Society of Fellows, is author of The Road to Nowhere: The Genesis of President
Clinton's Plan for Health Security (Princeton).
Copyright 1999, The Nation