As first lady, Sen. Hillary Rodham Clinton had championed an unsuccessful 1993 effort for wholesale reform of the entire health care system.
Now, Clinton, D-N.Y., again is talking about the urgency for reform. But this time, instead of grand schemes, she advocates much more targeted changes.
"As you know, I've done a little work on health care myself and still have the scars to show for it," said Clinton at a health care forum she held Monday in Buffalo.
The line, which Clinton has used before, elicited laughter from the standing-room-only crowd in Harriman Hall on the University at Buffalo South Campus. But she followed it up with a sobering diagnosis of what's wrong with the American medical system:
* The United States spends more on health care than any other country, yet life expectancy ranks 34th.
* More than 45 million Americans lack health insurance, forcing them to fend for themselves if they need medical care.
* Businesses are losing their competitive advantage to overseas firms as the cost of insurance continues to rise.
* Medical bills cause half of all U.S. bankruptcies, and most people in medical debt are workers with health insurance.
"We've got the incentives wrong. Our system is numb to the relationship between cost and result. It's blind to the need to pay for prevention. And it's deaf to the need to reward businesses that provide decent coverage for their workers," she said.
The medical system, for example, is willing to pay thousands of dollars to amputate a diabetic's feet but won't cover the preventive treatment that might avoid an amputation, she said.
The market, moreover, rewards businesses that unload health care costs onto employees, other employers or the government and punishes companies that try to provide decent coverage, she added.
Clinton, who is running for a second term and is considered a potential Democratic nominee for president in 2008, has been aggressively raising health care issues in recent public appearances.
She took several shots at the Bush administration, criticizing the Medicare prescription drug plan, plans to raise out-of-pocket costs for Medicaid recipients and the president's recent call for expanding health savings accounts.
She characterized health savings accounts as advantageous only for the healthy and wealthy.
So, what would Clinton do?
Among other things, she stressed "evidence-based medicine," a movement trying to help doctors figure out which treatments are supported by scientific research and which are ineffective. She couples that with a call for more comparative information for consumers about which therapies are the most appropriate, safest and cost-effective.
She also would encourage basing Medicare and Medicaid reimbursements to hospitals and physicians on performance measures.
Clinton cited a need for greater investment in information technology to expand the use of electronic medical records to avoid duplicating services, for bar codes to track medications and reduce errors and for encouraging hospitals and doctors to devise ways for their separate computer systems to communicate with each other.
Long-term care policies, she said, should favor home and community-based services instead of institutional care.
Clinton concluded that the United States must come up with a "uniquely American" system, suggesting that the solution is not to simply copy another country.
"It's about health care and the economy," she said. "But it's also about our moral values as a country."