The flier from Hillary Clinton's campaign declares in bold letters: "What's being said about Obama's health care plan." Obama's plan is "incomplete," "wrong" and "could leave as many as 15 million poor without any guarantee," the flier quotes from articles in The New York Times and on CBS News.

In response, a glossy mailer shows Obama surrounded by men and women in scrubs. "Everyone in this race has a universal plan for health care - including Senator Clinton," Obama is quoted as saying. The mailer accuses Clinton of misleading attacks.

The battle for the Democratic nomination for president is being fought over health care, as Clinton, Obama and John Edwards in particular have seized on the issue to showcase their differences. But independent policy experts say that while there are differences among the plans - particularly over the issue of mandates - they are far outweighed by the similarities.

"These plans are really similar. It's hard to find big differences," said Sara Collins, assistant vice president for the Commonwealth Fund, a private health policy foundation. "The big differences are between Democrats and Republicans."

In a UNH/CNN/WMUR poll released last week, 31 percent of Democratic voters listed health care as their top issue - the same number who listed the Iraq war. Nearly 60 percent put health care in their top three.

"Health care in the Democratic primary, its importance to voters, is what immigration is in the Republican primary," said Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health.

Mandates

The biggest difference separating Obama's plan from Clinton's and Edwards's is that theirs include a mandate that would force adults to get health insurance, similar to the one that exists for auto insurance in many states. Obama would mandate health care for children but not adults.

Edwards, whose plan was released first, and Clinton say Obama's plan leaves millions uninsured. "It is impossible to get universal health care if you don't have a mandate," Clinton has said.

Irwin Redlener, professor of public health at Columbia University's Mailman School of Public Health and a Clinton adviser, said those left out of Obama's plan would not be the poorest people, but those who have no savings, or who are young and healthy and would rather spend money elsewhere.

"Those most in need of health care won't be getting it until they get very sick or injured and go to the hospital," Redlener said. "It ends up being a tax burden on the rest of the public." He added that when healthy people opt out, the risk pool becomes smaller and those in the system are more likely to need care, so insurance premiums increase.

Obama told the Monitor that he chose to focus on affordability before considering a mandate. "My strong belief is the reason people don't have health care is not because they don't want it, but because they can't afford it," he said.

Obama says his plan would not exclude the poor because it would expand SCHIP and Medicaid and provide subsidies to those who need them. It would also allow children to remain on their parents' plans until age 25, taking care of a portion of the healthy uninsured.

Obama adviser Stuart Altman, dean of the Heller School at Brandeis University, said the problem with a mandate is that it would be difficult to force those above the subsidy line but with limited income to pay for health insurance. "Sen. Obama made a strategic call that said I'm not going to be in the business of forcing lower middle-income people to buy insurance if they can't afford it," he said.

Obama has also criticized Clinton and Edwards for not being specific regarding how they would enforce a mandate. His mandate for children, he says, could be enforced through schools. Redlener said Clinton's plan would likely be enforced through the tax system. Both Clinton and Edwards have said they would sign people up any time they come in contact with the government or health-care system, whether in an emergency room or in schools. (next page »)