Radical reforms of US healthcare are urgently needed - just don't expect dynamic solutions from all the presidential candidates, says Howard Berliner

The attempt to provide some form of universal access to healthcare in the US has been the bane of every president since Franklin D Roosevelt in the 1930s.

Only Lyndon Johnson was able to come close with the enactment of Medicare and Medicaid in 1965.

The most recent attempt came with the failed reforms of President Clinton in 1994. It is not a surprise, therefore, that political pundits say candidates should stay as far from healthcare reform as possible if they want to be elected.

Yet healthcare remains near the top of polls that measure what Americans are concerned about. What is a candidate to do? For the presidential campaign of 2000, the three major candidates have adopted three different positions.

Vice-president Al Gore has proposed an expansion of the children's health insurance programme and some reforms of Medicare;

former senator Bill Bradley has proposed an ambitious federally supported programme to give healthcare access to almost 95 per cent of the population; and Republican candidate George W Bush has stayed away from the issue completely.

Mr Gore was the first to announce his proposal, which revolved around the expansion of initiatives begun during the Clinton administration. The centrepiece was a plan to provide health insurance to all US children by 2005. This would be accomplished by an expansion of the current children's health insurance programme to cover children living at up to 250 per cent of the federal poverty level (from the current 200 per cent), and to allow children in families above this level to buy into the programme.

The proposal would also establish rewards for states that were effective in enrolling children and punishments for those that were not.

Needless to say, this proposal did not sweep analysts off their feet with its boldness and vision. On the other hand, it was a plan that could be accomplished easily and that would do much to remedy one of the most glaring inadequacies in access to care in the US.

Bill Bradley, Mr Gore's only Democratic challenger, released his proposal a few weeks later. This was a much bolder plan in which all children would be covered from birth to age 18 either by enrolment in their parents' health insurance, or in the Federal Employees Health Benefits Program. Families below an income threshold would be eligible for subsidies.

For adults earning below a threshold, the federal government would provide a subsidy that would allow people either to continue their current insurance or join the federal programme. Medicaid would be eliminated.

Finally, the Bradley plan would provide a drug benefit for people on Medicare. The price tag for this proposal was said to be $55bn-65bn per year, and the source of the revenues would be the federal surplus. The vice-president quickly challenged Mr Bradley's proposal, saying it was too expensive and that by putting so much of the surplus into this health plan, there would not be enough left to save the social security or Medicare programmes.

Mr Bradley responded by saying that big problems required big solutions and that incrementalism had not done anything to improve people's access to healthcare.

Most leader writers sided with him on this point, noting that the challenger had provided the basis for a debate around healthcare while the vice-president had offered only minimal changes to current policy.

In the first debate between Mr Gore and Mr Bradley in New Hampshire, Mr Gore took the tack of criticising the expense of the Bradley plan by saying the country could not afford it. This led to another round of editorialising in which writers bemoaned the fact that a candidate for office in the richest country in the world had said we couldn't afford healthcare for all our citizens.

The success that Mr Bradley has achieved so far (including very favourable poll results and the raising of large amounts of money) may force the vice-president to take more of an offensive. To some extent, Mr Gore is saddled with being part of the Clinton health reform proposals in 1992 and is clearly wary of going too far, too fast. Yet by going slower he may lose his natural advantage to the challenger.

While the US public is wary of the growth of the uninsured population and detests managed care, it does not want the government to run healthcare either.

Subtleties such as paying for care rather than providing it tend to get overlooked in the brief soundbites that pass for policy analysis in the US.

Despite the economy continuing to boom and the growth of the federal surplus, nearly 45 million people are uninsured and the number of children without insurance is rising.

This is not acceptable for a civilised country. We can only hope that this is the election that will make things change.

Howard Berliner is associate professor and chair of health services management and policy, New School of Social Research, New York.