WASHINGTON — It is a political paradox. Both in the Iowa caucuses and New Hampshire primary, voters ranked health care at the top when asked which issues most concerned them.
But health care has been almost a nonissue in shaping voters' decisions on which candidates to support, polls in the contests showed.
The results indicate that none of the contenders has found a way to draw clear distinctions for voters among their competing plans -- all of which represent ambitious efforts to provide insurance to many of the nearly 44 million Americans without it.
"All of us have been unsuccessful at developing a differentiated position," said Ed Reilly, the pollster for Rep. Dick Gephardt of Missouri. Gephardt centered his presidential campaign on a proposal to provide nearly universal health care, but withdrew after a poor finish in Iowa.
The plans from the major Democratic candidates share a common thread -- they would expand coverage mostly by enlarging public programs for the uninsured, especially a state-federal partnership that covers children in working-poor families.
The key distinctions center on diverging approaches for controlling rising health-care costs -- an issue that none of the candidates has spotlighted in the nomination fight.
In the general election, however, health care looms as one of the clearest contrasts between President Bush and the eventual Democratic nominee. The differences are huge between the Democratic proposals and Bush's plan to expand insurance through tax credits and to control exploding health-care costs mainly through limits on medical malpractice lawsuits.
Nothing has shaped this campaign's Democratic health-care proposals more than President Clinton's failed effort to guarantee universal coverage. From the collapse of the Clinton plan -- which helped trigger the Republican takeover of Congress in 1994 -- the Democratic contenders have learned two lessons.
One is to minimize changes for the nearly 85% of Americans who have health insurance -- they would feel few effects from any of the Democratic plans.
The second is to avoid confrontations with business. Clinton's proposal to require most companies to contribute to coverage for their workers drew staunch resistance from small businesses.
None of the leading Democratic candidates would ask employers who don't provide insurance to contribute to coverage. Because of this, the plans carry substantial price tags for taxpayers -- a potential vulnerability against Bush.
