Facing growing consumer concern over soaring costs, America's health insurers are more eager to participate in reform now than in the 1990s, but they will still fight any attempt to reduce their profits, policy experts say.
If reform means requiring insurers to be much more efficient and would affect their bottom line, they'd probably oppose it, said Robert Laszewski, a health-care consultant at Alexandria, Virginia-based Health Policy and Strategy Associates who has covered the sector for three decades.
Like any stakeholder in reform, the industry would resist any demand that they change their behavior.
The spiraling cost of health care has risen to the top of voters' domestic concerns in national polls, and health insurers have been lambasted in filmmaker Michael Moore's new documentary, SiCKO.
Unlike a decade ago, big business, consumers and unions say the growing crisis in America's health-care system, which is dominated by the private sector, must be dealt with. And the insurance lobby has stepped forward with a plan that includes tax credits and subsidies, which it says will cover 45 million uninsured Americans.
It's a stark contrast to 1993, when former first lady and current Democratic presidential candidate Hillary Clinton's sweeping universal health-care plan was roundly rejected after she failed to elicit critical feedback from those outside the administration or from the industry.
The powerful insurance lobby reacted with a now-infamous television campaign using actors portraying a middle-class American couple, Harry and Louise, who were perplexed and annoyed at the perceived complexity of the plan.
The health insurance industry paid a big price for that campaign, said Nancy Chockley, head of the National Institute for Health Care Management Foundation. They didn't get reform of the system and came to be seen as the enemy.
The problem of spiraling health-care costs has worsened since then. Some 44.8 million Americans, or about 14 percent of the population, lacked health insurance in 2005, up from 39.7 million in 1994. Meanwhile, Americans have seen double-digit annual increases in their health insurance costs.
The insurance industry says it is trying to address these issues.
Unlike the early 1990s, we are being proactive and are not going to wait around for individuals to come up with proposals, said Karen Ignani, head of America's Health Insurance Plans, an industry lobbying group known as AHIP.
AHIP's own plan unveiled last November uses tax credits and subsidies to expand coverage for poorer Americans. The 10-year plan would cost $300 billion.
The trade group says the plan promotes coverage for every American but doesn't go as far as some state programs, such as Massachusetts -- which mandates employers cover workers -- nor does it require individuals to have insurance before receiving care.
AHIP's Ignani said that more people insured means more will have access to cheaper preventative care, rather than ending up in emergency rooms, the most expensive way to get treated.
Caring for the uninsured in the ER costs $50 billion a year - adding $1,000 annually per employee's health-care plan, and so a plan such as AHIP's would largely pay for itself, she said.
ARE TAX CREDITS ENOUGH?
Tax credits are a significant part of various plans offered by the Bush Administration and other conservatives. The AHIP plan proposes a credit of up to $500 for low-income families.
But many policy experts say tax credits will simply not be enough to insure tens of millions of Americans.
Gary Claxton, vice president of the Kaiser Family Foundation, said he was skeptical of the effectiveness of tax credits and trying to convince people to take products that offer less and less -- I don't know that this is going to be acceptable to a broad range of the public.
The AHIP plan has also been criticized by policy experts as short on detail.
It is an attempt to signal a willingness to engage, said Len Nichols, a health-care economist at nonpartisan think tank the New America Foundation. It doesn't really take on the hard problem of making the markets work better.
It is also in the industry's best interest to promote universal coverage as it could naturally expand the market, according to Harvard University Professor Robert Blendon.
By coming up with a proposal of their own the industry has shown it wants to shape reform rather than just react negatively to proposals, he added.
Health insurers contend they have already taken measurable steps to cut their own profits and take costs out the system.
We have been looking at ourselves to get us to be more efficient, and to get administrative costs lower, said Alyssa Fox, a vice president of the Blue Cross Blue Shield Association, an umbrella group for mostly nonprofit plans.
AHIP's Ignani said that unfortunately some politicians look to us as the only place where costs can be cut.
Jason Furman, director of the Hamilton Project, an initiative of the Washington think tank the Brookings Institution, said that if reform discussions turn to cost reductions, it will pit health-care providers against health insurers against consumers.
But some industry experts say that ultimately the degree to which America's health-care system is reformed depends on how much the country's voters want the system to change.
If the American voter absolutely wants health reform, politicians will overcome their fear of special interests in the industry and make it happen, consultant Laszewski said.
Right now, they fear special interests more than they fear the electorate.