COLUMBIA, S.C. — It wasn't Iraq. It wasn't illegal immigration. And it wasn't abortion.
If there was one issue that could have swamped the Democratic presidential debate held Monday in Charleston, it was health care.
"One of the most popular topics that we got questions on was health care," said debate moderator Anderson Cooper of CNN. "We, frankly, were overwhelmed with videos on health care, so we put several of them together."
While the videos differed in detail, they all asked the same broad question: What should be done to improve health care in a country where 45 million have no health insurance?
The Democrats on stage Monday night, like most of their Republican counterparts, have plans to expand health care coverage.
But political and health care policy experts say the differing plans underscore the problem: Political leaders are just as divided about what should be done as the people they represent.
The result? Lots of talk, those experts say. Lots of plans. And little real hope that substantial change is on the way.
"I don't think there is going to be a big sweeping solution," said Dr. Paul DeMarco, an internist who has practiced in Marion County, S.C., for 14 years. "It's more of a societal-cultural issue than a health care issue at this point."
In South Carolina, the issue has special relevance. About 17.3 percent of the state's residents — more than 720,000 — have no health insurance, according to 2005 figures from the U.S. Census Bureau. Only nine states have a higher percentage of uninsured residents.
The issue of health coverage is even more important because South Carolina is a national leader in rates of diabetes, stroke and heart disease.
DeMarco, who heads up a Democratic working group on health care, said up to 20 percent of his patients have no health coverage.
"I spend a lot of time scrambling through my sample closet (for medicines)," he said.
DeMarco related the case of an uninsured diabetes patient who had a swollen, infected foot. The man, DeMarco said, waited too long to seek treatment. He did not have to have his foot amputated, but it did require extensive surgery, DeMarco said.
Doctors across the country can cite similar cases. The percentage of uninsured Americans has stayed in the same range for the past decade. Just under 16 percent of Americans had no coverage in 1995-1997, according to Census Bureau figures. That percentage dipped to 14.4 in 1998-2000, rose to 15.1 in 2001-2003 and ticked up again to 15.5 in 2002-2004.
Three general schools of thought have emerged in the quest to expand coverage.
The first, supported by DeMarco, calls for a national health care system that would cover all Americans.
A few Democrats _Rep. Dennis Kucinich of Ohio, former North Carolina Sen. John Edwards and Sen. Barack Obama of Illinois — have plans they say would cover all Americans.
A second approach focuses primarily on expanding current programs like CHIP, the Children's Health Insurance Program, to cover more people.
A third approach, backed mostly by Republicans, would help Americans pay for private accounts that can be used to cover health care costs.
(Though he's not a candidate for president, Republican Sen. Jim DeMint of South Carolina has been an ardent supporter of that approach.)
Sen. Hillary Rodham Clinton, D-N.Y., tried and failed to install massive changes in the health care system when her husband, Bill Clinton, was president. Her failure, one she now uses to poke fun at herself during her presidential campaign, illustrates how difficult making substantial changes can be even when the White House and the Congress are controlled by one party.
"There are deep philosophical differences in Congress," said Robert Moffit, director of the Center for Health Policy Studies at the Heritage Foundation, a conservative think tank in Washington, D.C. "A lot of it has to do with the government's role in health care."
Each proposal to overhaul the U.S. health care system comes with a pointed criticism from opponents. National health care would be inefficient and costly; expanding current programs isn't a big enough fix and would not cover everybody; and private accounts won't come close to covering the surging costs of health care, critics say.
"People are clear in what they don't like," said Robert Moffit, director of the Center for Health Policy Studies at the Heritage Foundation, a conservative think tank in Washington, D.C..
Moffitt served in the Reagan administration and helped Mitt Romney craft a health care plan for Massachusetts when Romney, now running for president, was governor of Massachusetts. "They don't like HMOs. They don't like paperwork. They don't like lawyers. The problem is, they're not really clear on what they actually like, what they want."
Moffit said he thinks the GOP approach — private accounts to cover health care costs — would be most effective in reducing the number of people without coverage.
He said the Clinton effort failed because people with health insurance did not want to be forced into changing their plans.
"People were worried about that," Moffit said. "That was frightening to a lot of people."
For his part, Democrat DeMarco said universal coverage through a national health care plan is what he wants to see.
"I think it's the best solution that we've got," DeMarco said. "It's got problems. I just think it's a better set of problems. Everybody gets covered."
Whose plan does DeMarco like best?
"The Kucinich plan," DeMarco said.
Kucinich calls for an end to what he describes as "for-profit medicine" and the establishment of a not-for-profit system in which everyone is covered.
But Kucinich is, at best, a long shot to win his party's presidential nomination. Polls have shown him to be in the low single digits — and that is only in the polls where Kucinich was thought to be a significant enough factor to warrant inclusion.
That's not the case in South Carolina.
DeMarco said he knows Kucinich is a long shot and he is not supporting the Ohio congressman. He just likes Kucinich's approach on health care.
"Right plan," DeMarco said. "Wrong man."
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