Election 2008 will feature a fundamental debate about healthcare. That debate will offer a stark contrast in goals and strategies: for or against coverage for all; a common government guarantee versus individualized, "market based" insurance.

Voters rank healthcare just below Iraq as a top concern. A March New York Times/CBS News poll found that nearly two-thirds of Americans believe government should guarantee healthcare to all, and a majority say they're willing to pay higher taxes to get it. Healthcare looms very large for Democratic and independent voters. For Republican voters, however, other issues--immigration, tax cuts--rank higher. Not surprisingly, healthcare has moved quickly to the center of the Democratic debate, while Republican candidates have said comparatively little about it.

Among the GOP candidates, Representative Duncan Hunter bluntly states a common theme: "I'm against universal coverage." Republicans generally oppose mandates to provide healthcare, instead advocating "market mechanisms" that, they say, would make healthcare less expensive. As governor of Massachusetts, Mitt Romney led the effort to implement a universal state program that required companies and individuals to get healthcare. But he says very little about his plan now. "I don't like calling it universal coverage. That smacks of Hillarycare," Romney says. He adds, "The Democrats' path is always government-mandated, government-run, government insurance...[which is] almost by definition going to be inefficient, ineffective and expensive."

Former New York Mayor Rudy Giuliani has taken the lead in the Republican field. Scorning Democratic plans as "socialized medicine," Giuliani says the "problem with our health insurance is it's government and employer dominated. People don't make individual choices." He would accelerate the move away from employer-based insurance, giving individuals a tax credit of as much as $15,000 to help pay for their own. But he wouldn't require people to self-insure, so with the young and healthy forgoing insurance and insurance companies imposing a higher premium for those purchasing outside a broad pool, this kind of individualized insurance is likely to drive costs up and coverage down.

Among Democrats, the debate was initially focused on incremental reforms, but activists demanded more, and the broken system requires it: Nearly half of people in the Times/CBS poll have had their coverage cut or had to pay more. A fourth of those with insurance reported that they had done without tests or treatment because it wasn't covered by their plan. Forty-seven million--15 percent of Americans--do not have health insurance, up some 6.8 million over the past seven years. Only comprehensive reform can address these problems.

Of the leading contenders, John Edwards was the first to put forth a comprehensive plan, projecting its costs and calling for rolling back many of Bush's tax cuts to pay for it. Barack Obama has followed suit, and a wary Hillary Clinton has begun a piecemeal rollout of what she promises will be a comprehensive plan. With little notice, Chris Dodd has laid out a comprehensive plan, similar to those of Edwards and Obama. Both Edwards and Obama would require employers to provide insurance for their employees or pay into a public plan. Employees could keep the plans they have at work or enroll in a Medicare-like public entity. Both candidates believe a public plan, open to all, would keep insurance companies honest. Edwards would require every person to have insurance; Obama would not. Edwards, Obama and Clinton all have detailed initiatives on saving costs, from bulk negotiations on prescription drugs to computerized record-keeping.

In contrast, Representative Dennis Kucinich and Mike Gravel argue forcefully for a single-payer plan--basically Medicare for all. Kucinich has co-sponsored legislation with Representative John Conyers that would allow people to choose their own doctor and eliminate insurance companies, using the hundreds of billions saved to cover everyone. Since it takes on the insurance industry directly, the Kucinich single-payer plan would trigger a furious, multibillion-dollar campaign by the insurance industry to scare the hell out of voters, a sequel to the "Harry and Louise" campaign that torpedoed the Clinton plan in 1993-94.

Obama and Edwards hope to avoid a direct face-off with insurance companies by offering them, as Obama puts it, "a seat at the table," but they "don't get to buy every chair." On a level field, a public plan competing with the insurance companies would offer more comprehensive and less costly coverage. But will the field be level? As Trudy Lieberman reveals on page 14, insurance lobbies have pocketed massive subsidies for private plans that now compete with Medicare. The drug lobby has blocked Medicare from making bulk purchases of prescription drugs. With hundreds of billions at stake, no comprehensive reform can avoid taking on these powerful lobbies.

It's early in the campaign, yet it's already clear that we are headed into a high-stakes debate on healthcare. What will replace the broken corporate healthcare system: a broad public guarantee, or individualized plans purchased on the market? Do we fare better together or on our own? Americans want something done. The next year should provide them with a clear choice.

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