The leading presidential candidates' proposals on health care reform are more detailed -- and perhaps more realistic -- than those of past elections.

That could bode well for the chances of significant reform in the next four years.

"Both sides of the aisle give me hope that we are going to have an adult conversation," said Len Nichols, a health care economist at the New America Foundation, a research group that focuses on bipartisan approaches to public policy issues.

In the Democratic presidential primary, Sen. Hillary Rodham Clinton of New York and Sen. Barack Obama of Illinois have vowed to make reform a priority, with the stated goal of providing coverage for everyone.

For his part, Sen. John McCain of Arizona, the Republican front- runner, has put forth a detailed proposal that could make health insurance more affordable for a large number of the uninsured.

Former Arkansas Gov. Mike Huckabee also has outlined how he would reform the health care system -- though in far less detail than the other candidates.

All but the most partisan economists would acknowledge that there are good ideas on both sides. "Every single candidate for president, both sides of the aisle, has talked about how to make health insurance more affordable and accessible for all Americans," Nichols said. "There is a common recognition that we have to do something."

There is a clear ideological divide in how Republicans and Democrats would reform health care. The differences are less pronounced within the parties, particularly among Democrats.

Obama's and Clinton's proposals would build on the existing system in which most people under 65 get health insurance through their employer. Both would increase regulation of insurance companies. But both have stressed the importance of giving people choices when picking a health plan.

Huckabee's and McCain's proposals would build on the market for individual insurance, through changes in the tax code, potentially altering the role of employers. Both also propose less regulation for insurance companies.

Despite the differing approaches among the two parties, there is common ground.

All of the candidates' proposals include subsidies to help people with modest incomes buy health insurance. And McCain, Clinton and Obama support a long list of initiatives to make the health care system more efficient.

The list includes putting more emphasis on prevention and disease management, encouraging the adoption of information technology and reforming the medical malpractice system. The three candidates also would require hospitals and doctors to disclose information on prices and quality.

For his part, Huckabee supports encouraging prevention and the adoption of information technology.

That common ground could be all-important.

Health care reform historically has not fared well in Congress, and no matter who wins in November, any proposal will need to make it through a gantlet of congressional committees. For this reason, many analysts contend that any significant reform will require bipartisan support.

Whatever is passed by Congress is certain to be different than what the candidates propose. But their proposals provide a starting point.

Broad and similar

Clinton's and Obama's proposals are broad and largely similar in their approach.

Both candidates would prevent insurance companies from linking premiums to health status -- a proposal designed to help older people or those in poor health who don't get insurance through their employer.

Some of the key ideas shared by Obama and Clinton include:

- Imposing a so-called "play or pay" mandate, requiring large employers to offer workers insurance or pay an unspecified tax.

- Setting up exchanges where individuals could buy approved health plans from private insurers. Clinton's proposal also would let employers buy insurance through the exchange.

- Creating a new public health insurance plan with benefits similar to the standard plan available to federal employees.

- Rolling back tax cuts put in place by the Bush administration for families with incomes of more than $250,000 to help cover the cost. Obama also would raise the tax on capital gains to 28% from its current rate of 15%.

The most significant difference between the two candidates is Clinton would require people to buy insurance. Obama would require only children to have insurance initially.

But Obama has not ruled out mandates.

Obama estimates that his proposal eventually would cost $50 billion to $65 billion a year. Clinton has put an estimated price tag of $110 million on her proposal. But both candidates are vague on how the proposals would be funded other than rolling back some of tax cuts put in place during the Bush administration.

A different approach

The Republican candidates would take a different approach, encouraging people to buy health insurance in the individual market.

Huckabee and McCain would allow people to deduct the cost from their taxes, giving them the same tax break now available to people who get insurance from their employer.

The underlying idea is people will become more cost conscious if they spend more of their own money on insurance and health care. That in turn could force hospitals, doctors and others to become more efficient, slowing the rise in costs.

The two candidates also support subsidies, in the form of tax credits, to help people with low incomes buy health insurance. Huckabee hasn't provided specifics on the size of the subsidies. McCain backs tax credits worth $2,500 for an individual and $5,000 for a family.

"It's the most serious proposal on the Republican side in a presidential election in quite some time, clearly as far back as I go," Nichols said.

People who don't pay any federal income taxes, or who pay less than the credit, would be given the difference to buy health insurance.

"What McCain does is actually create a universal system," said Robert Moffit, a health care economist with the Heritage Foundation, a conservative policy research group. "It's not mandatory, but it is universal."

At the same time, McCain would restructure the tax code to eliminate or limit the tax break given to people who get health insurance through an employer.

"You are basically talking about upending the entire tax structure for health care," Moffit said.

Neither McCain's nor Huckabee's proposals would make health insurance affordable for people with pre-existing medical conditions.

Like their Democratic counterparts, neither McCain nor Huckabee has provided details on how he would pay for his proposal.

The candidates also have largely sidestepped the hard choices and tradeoffs that many economists contend will need to be part of any significant health care reform.

That includes the pending fiscal collapse of Medicare, projected to be insolvent by 2019.

Yet, despite their differing approaches, the candidates share many ideas. And that could help in the arduous process of getting health care reform through Congress.

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