Hillary Clinton single-mindedly contrasts her health care position with Barack Obama's, which clearly means that her campaign believes it is a winning issue for her, as opposed to, say, the Iraq war.
Not one Clinton endorser fails to mention that she is "for universal health care" and Obama is not: it is at the very top of their talking points, and they say it like they mean it. The problem is that Clinton isn't really for universal health care, or she would be advocating a socialized system not unlike Canada's, Great Britain's, or France's, among some of the countries that offer free and accessible medical care.
Instead, she is promoting a plan that is essentially a Swiss model, or perhaps a Massachusetts one, and calls for compulsory health insurance. In Paul Krugman's world of theory, this is great and will lead to all people having access to good health care they can afford. The reality is far different. Even in Switzerland, a wealthy, law-abiding, health-conscious country, a significant proportion of the population is not insured (in 2006 alone, nearly 2% of Swiss adults behind in their monthly payments were added to the ranks of those deprived of insurance; this would be equivalent to 6 million Americans). There are many reasons for this, some of them seemingly irrational, but the perfectionist, social-democratic Swiss system has failed to resolve the problem, and what are the odds that a Clinton administration would, especially if it doesn't even acknowledge the challenge?
Clinton refuses to address the issue of enforcement of a law making health insurance obligatory, and that is understandable. She knows it is not enforceable, and is therefore irrelevant. As Elizabeth Edwards pointed out, Clinton believes her position is a better starting point in a negotiation with the health care industry than is Obama's. That may be the case, but it is also a fairly explicit acknowledgement that she doesn't believe universal health care is achievable under her plan.
Comparing the enforcement of adult universal health care to that of children, as many Clinton supporters are doing, is inappropriate: there is far more leverage to be applied on parents and guardians when it comes to the children in their care than there is on adults (and far more emotional incentive for adults to provide for the children in their care than for themselves). Again, the plain evidence of the quandary is Clinton's refusal to address how she would impose the mandate on adult individuals.
It is odd that a significant proportion of progressive commentators have lined up behind her plan when they must know that short of a Canadian-style single payer system, this country will not achieve universal health care. But they probably also realize that Clinton's own 1994 debacle on the topic has made any attempt at truly socializing health care an impossibility for decades to come in the US.
The difference between Clinton and Obama on health care matters (and not necessarily in the way that Krugman et al say it does), but it is immaterial when compared to the Republican stance. We are thankfully free of Rudy Giuliani's silly worship of US health care, but the underlying idea that the American system produces the best care in the world still has life in it despite some glaring facts.
Even if Canada, Cuba, Great Britain and France aren't quite the paradisiacal medical havens that Michael Moore portrayed in Sicko, the numbers are striking: the US has a lower life expectancy than 42 countries, and a higher infant mortality rate than 32 countries, most of them in Western Europe, but also including Canada, Singapore, Japan, etc, etc. That in itself should be a frightening indictment of the US health care system, since it is surely accepted that keeping people alive, including new-born infants, is a pretty good measure of medical success.
Beyond that, it is striking how similar the challenges are in vastly different systems. In recent personal, anecdotal research, a group of people from half a dozen Western countries ranging from socialist democracies to, well, the US, mostly had the same complaints, falling roughly along two lines: denied coverage, and lack of attention by general practitioners.
It really doesn't make much difference to most sick people that a procedure is delayed or denied because of an inept public bureaucracy or an inept greedy private enterprise. Both are frightening, intensely frustrating and debilitating experiences, and in both cases we are paying for the pain, either through taxation or through insurance payments.
As for visits to primary care providers, here too, the similarities are noteworthy. Many Americans with insurance (let's not even talk about the horror of those without) are not enjoying the benefits of the much-vaunted "choice" that is supposed to flow from a free-market health-care system. Instead, they are driven by insurers to a relatively small pool of preferred providers whose payments are capped and who spend a minuscule amount of time and attention on each patient. How is this any better than a government-sponsored version of the same thing?
One can argue whether it is preferable to pay directly (insurance) or indirectly (taxes) for dismal service, but what is inarguable is that the US spends by far a larger proportion of its high income on health care for the mediocre results outlined above. And even the most market-driven observer can't fail to see that this is not satisfactory. It is also catastrophically inefficient, and soul-crushing, that most Americans' health is directly tied to their employment, making them indentured to their employers and in a constant state of fear about the possibility of losing their job and health care at any moment in time.
In all cases, it is clear that the very wealthy receive the best care, by far, because health care costs are of no consequence to them. They are the ones who patronize doctors whose fees are not covered by insurance because they are so high, and who are able to travel to whatever private clinic or hospital in whatever country will provide the best treatment. Perhaps this is as it should be in a market economy, but it is interesting to note that Republicans are not calling for market forces to have a stronger impact on the health care system. Rather, they are content to passively let insurance companies dictate the very anti-capitalist terms of engagement and to terrify Americans into thinking that providing low-income, uninsured American children with medical care is the first step towards a Marxist state.
It is typically dishonest of Clinton to instill the hope of universal health care when she knows from her own experience, and that of others, that her plan is not enforceable. If only she wouldn't let herself be intimidated by Republicans and the health care industry, and called for real universal health care, now that would be a worthy talking point.