Obama Health Plan Would Keep Employer System : Uninsured could buy coverage through a private plan or one sponsored by the federal government.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Keys on Tax Changes, Cost Control,” June 2008, p. 34, for more details on Sen. McCain's plan.) While in the long-term it might be a good idea to move away from that system, that should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are somewhat murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute. However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. Unlike in 1992, there has been far more “plowing of the ground,” he said. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Naomi P. Senkeeto, a health policy analyst at the American College of Physicians, agreed that there are reasons to be optimistic about health reform passage this time around. This year, both candidates have recognized the need for health care reform and all of the stakeholders are at the table, she said.

While much depends on the new president and the makeup of Congress, it is increasingly clear that how the reform will look will also depend on how quickly the issues are taken up following the inauguration. There is a growing sense that given all the competing priorities, if health care is not addressed in the first 100 days it will be increasingly difficult to pass. “It's really important to hit the ground running,” Ms. Senkeeto said.

Sen. Barack Obama's plan also includes a universal coverage mandate for children.