A work in progress

September 21, 2007

Aconsensus seems to be developing on the nation's approach to health care that recognizes a responsibility shared by the individual as well as society.

Huge disputes remain about how to achieve universal coverage, and those disputes are expected to play a central role in the 2008 presidential campaign. Assuming a general approach is effectively ratified in the election, ironing out details of new legislation may still require years.

Yet Sen. Hillary Rodham Clinton's formal re-entry into the debate this week - more than a dozen years after her debacle in promoting a total redesign of the health care system - marked a milestone. While she has moderated and scaled back her approach, the rest of the political community has mostly moved in her direction. This is a very hopeful sign.

For economic reasons, if for no other, society has a large stake in ensuring that all Americans have affordable access to preventive and primary health care, because ailments that go untreated will sooner or later wind up on the public tab - often in the emergency room. Accepting this obligation builds on earlier understandings that the society has a duty to care for the elderly, children, pregnant women, disabled people and veterans.

At the same time, though, Mrs. Clinton has come around to a position, often espoused by conservative think tanks, that individuals have a responsibility to obtain medical insurance on their own to the extent that they are able. This so-called individual mandate included in Mrs. Clinton's latest health care proposal also appears in the health care plan offered by fellow Democratic hopeful John Edwards and in a bipartisan proposal for universal health coverage introduced in the Senate by Democrat Ron Wyden of Oregon and Utah Republican Robert F. Bennett.

Republican presidential hopeful Mitt Romney won enactment of an individual mandate when he was governor of Massachusetts, which is now a testing ground for the concept, though Mr. Romney has shied away from such a mandate at the national level.

Indeed, requiring Americans to buy health insurance, especially young, healthy people who have more urgent demands on their limited incomes, is hard to swallow at first. But Sen. Benjamin L. Cardin of Maryland argues persuasively that such a national mandate - along with affordable insurance plans tailored to meet the varying needs of the states - may be the next, best step to be taken toward universal coverage as larger policy battles are waged.

Should employers be required to offer health insurance, as Mrs. Clinton proposes, or should tax benefits be shifted from employers to workers to buy their own insurance, as Mr. Wyden suggests? Should federal health insurance programs for government workers and the elderly be opened to other adults, as several Democrats advocate, or should a greater emphasis be put on incentives to encourage the private insurance market to offer affordable products, as most of the Republican presidential candidates argue?

The wisdom of approaching such controversial decisions cautiously was borne out by Mrs. Clinton's last experience. But at least this time, she and her colleagues are starting with a vision of shared responsibility that should provide a solid foundation for what comes next.

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