Candidates aiming for the presidency in 2008 will have a tough time campaigning without diving into health care reform, according to analysts who say the nation's health care delivery and finance system is at the top of voters' domestic concerns.

Health care is second to the war in Iraq as the most important problem for the government to address, according to a recent poll of voters by the Menlo Park, Calif.-based Henry J. Kaiser Family Foundation.

"This is the first time we've seen health care before the economy," said Larry Levitt, a Kaiser vp.

According to analysts, the issue is multi-pronged. First, escalating health care costs are affecting businesses, which are more and more asking their employees to help foot the bill, making access to health care coverage increasingly unaffordable for employees and their families.

At the same time, the number of people without health insurance, currently about 45 million, keeps rising, fueling concerns among the insured that they might one day join the ranks of the uninsured.

"The number of uninsured is climbing and the costs are climbing," said Mr. Levitt. "People are more worried about paying more for their health care than they are about terrorists or their income keeping up with inflation."

Since 2000, health care costs have risen five times faster than general inflation, according to Brian Klepper, executive director of the Atlantic Beach, Fla.-based Center for Practical Health Reform, a nonpartisan group working with employers, health providers, insurers and others groups on ways to help reform the nation's health care system.

"If you asked any of the (presidential) candidates, they will all say they plan to do something about health care costs," he said.

As of now, few are speaking up, other than making general campaign promises to address rising costs and to help the uninsured, analysts say. Katie Strong, director of congressional and public affairs with the Washington-based U.S. Chamber of Commerce, said it's too early in the campaign for detailed health care platforms.

"I don't think Americans even know what they want in a health care system," she said. "But I believe we are at the tipping point for reform."

Tackling the issue with details this early in the game would be a bad political move, analysts stressed.

"There is an advantage to not getting too detailed, because if you issue details, interest groups will start mobilizing.Ö There is a political risk" with that, said Frank McArdle, manager of Hewitt Associates Inc.'s Washington office.

According to Mr. McArdle and others, Democrats typically address health care issues much earlier in the campaign than Republicans, who often see health care as an issue secondary to other concerns, such as the economy and taxes.

"The entry fee for Democratic candidates is to support universal health care," said Neil Trautwein, vp and employee benefits policy counsel with the National Retail Federation in Washington.

"The Republicans, with the exception of (former Massachusetts Gov. Mitt) Romney, have been reticent with health care. You can't even find anything on their Web sites about it," Mr. Trautwein said.

Much of the talk up to this point has centered on expanding coverage, analysts say.

"Most of what I hear from the candidates is broadening coverage and less about improving the quality of care or controlling costs," said Ted Nussbaum, Stanford, Conn.-based director of health care consulting in the United States for Watson Wyatt Worldwide. "It's hard to put your arms around exactly what they are trying to do."

Democrats

The top three Democrats aiming for the party's presidential nomination—Sen. Hillary Clinton, D-N.Y., former Sen. John Edwards, D-N.C., and Sen. Barack Obama, D-Ill.—have touted the term "universal coverage" with only Sen. Edwards providing details.

Sen. Hillary Clinton, D-N.Y.

Of all the major candidates, none has greater background on health care issues than Sen. Clinton. Her husband, then-President Bill Clinton, chose her to develop his sweeping health care reform package.

The chief reason the package failed to win congressional approval, President Clinton said at the time, was that it tried to do too much too soon.

In contrast to the detail-rich 1,300-page health care reform package she advanced as first lady, Sen. Clinton's current health care positions are sparse in detail. She does support, though, opening up the State Children's Health Insurance Program to enable parents of beneficiaries gain access to coverage.

She says she also supports giving tax credits to small employers to help them provide health coverage. Additionally, Sen. Clinton says prescription drug costs are too high, a problem she says she would address by making it legal to reimport drugs and to improve the process of approving generic drugs.

John Edwards, D-N.C.

"How would you pay for health care? A lot of (Democratic) candidates are silent on that issue," said Mr. McArdle. "Edwards is the only one to say how he would pay for that."

According to Mr. Edwards' plan, outlined on his campaign Web site www.johnedwards.com, employers would be required to either cover their employees or help finance their health insurance. The plan also would create new tax credits that individuals could use to effectively reduce the cost of health insurance premiums; expand Medicaid and State Children's Health Insurance Program to cover many more lower-income uninsured individuals; and reform insurance laws so that insurers would not base rates on an individual's age or medical history.

Mr. Edwards also proposes to create regional "Health Care Markets," which he describes as purchasing pools set up by a state or groups of states that would offer a choice of competing health insurance plans. The markets would be available to individuals not covered by group plans or to employers that don't offer insurance.

According to analysts, the Edwards plan would be financed, at least in part, by raising taxes on households earning more than $200,000 annually.

Sen. Barack Obama, D-Ill.

Sen. Obama, like Sen. Edwards, also has stated the goal of providing universal coverage by 2012.

However, the details have been slow in coming; Sen. Obama has promised to release his proposal in the upcoming weeks.

On his Web site, www.barack obama.com, Sen. Obama's campaign provides details of the problems that exist in health care and coverage, along with promises to expand health care to children and to fight disparities in the treatment of the poor and minorities.

Republicans

As for the top three Republicans seeking the presidency—Sen. John McCain, R-Ariz., former Massachusetts Gov. Mitt Romney, and former New York Mayor Rudolph Giuliani—two have provided little to no information on health care, except for supporting a market-driven approach to reform.

Rudolph Giuliani, R-N.Y.

The former mayor of New York so far has devoted little attention to health care issues.

He has, however, stated that he supports a market-driven expansion of health care coverage.

He's also drawn a hard line against a universal single-payer approach and has accused Democrats of moving towards socialism with their proposals for universal coverage.

Sen. John McCain, R-Ariz.

Sen. McCain, while remaining quiet on his health care reform positions, has a record for supporting changes in the system.

Sen. McCain has supported measures to reduce costs of prescription medications for the elderly and expand coverage for children. He's also supported medical malpractice reform by capping noneconomic damage awards, which he says has contributed to the rise in health care costs affecting all Americans.

Mitt Romney, R-Mass.

Mr. Romney has offered the new universal coverage system in Massachusetts—a state reform he ushered in before he left his seat as governor—as an initiative that could possibly become a national model.

The Massachusetts health reform bill, signed in April 2006, requires most individuals to be covered by a health insurance plan by July 1

Those who fail to obtain insurance by 2008 will be penalized and the law creates a state-subsidized program in which lower-income uninsured individuals can obtain coverage from commercial insurers.

The law also imposes a surcharge of $295 per employee on all but very small employers that do not offer coverage.