ASHINGTON - The nation's rocketing economy has produced 9.5 million jobs in the last four years and raised wages for even the lowest-paid workers. But as Americans buy more homes, cars and other consumer goods, the number buying one important staple - health insurance - has not budged.
Now, the 44 million Americans without insurance are taking a prominent place in the national spotlight, thanks to the Democratic presidential primary. And in Vice President Al Gore and former senator Bill Bradley, the nation has a chance to sort out how far it is willing to go, if at all, toward promising health care for everyone.
In proposals issued recently, both Democratic candidates have promised to cover all 11 million children who have no insurance, with taxpayers paying the entire cost for the poor and many near-poor. Gore and Bradley would also give substantial help to the parents of the nation's poorest children.
But they split over one growing class of people: the millions of adults who are not quite poor, but who find insurance so expensive that they do not buy it.
Almost 17 percent of full-time workers have no insurance, often because employers do not offer it or have shifted costs to employees. Many of the new jobs created in the current boom are at small businesses, which are less likely to offer coverage.
''It seems that when you're considered working poor, the options aren't there for you,'' said Juanita Turner, a Worcester mental health worker and mother of a 17-year-old daughter. Her union recently went on strike when her employer tried to shift some insurance costs to workers, a move Turner said would force many to go without coverage.
Such workers sit on the fault line between Bradley and Gore: Bradley has proposed an expansive plan that helps people even further up the economic ladder than Turner - and which carries an expansive pricetag to match. Gore, by contrast, would spend money on the poorest and near-poor while offering only limited help to others.
''They say if you want to fill a cup, you start at the bottom,'' said Jonathan Gruber, an economics professor and health policy specialist at the Massachusetts Institute of Technology. ''The question is: How high do you want to fill the cup?''
The question has barely been raised among the Republican presidential contenders. But it has sparked the sharpest debate yet in the Democratic campaign, and polls show that voters are likely to make it a general election issue. With surveys suggesting that no candidate can win the Democratic nomination without a strong health plan, Bradley boasts that he is proposing a big idea to attack a big problem. He has derided Gore's plan as ''definitely timid.''
The tactic has helped raise Bradley's profile among Democrats, said Robert Blendon, a professor of health policy at Harvard who studies public opinion. If nothing else, it has put the word ''bold'' next to Bradley's name in headlines.
Gore, by contrast, talks freely of his plan's limitations, and his staff uses the word ''incremental'' to describe it. They say Bradley's plan is too expensive and would divert dollars from other purposes, such as shoring up Medicare. ''Alchemy was a big idea, but it wasn't a good idea,'' Gore said at a recent campaign event.
The true cost of the two plans is open to debate. Bradley says he would spend up to $650 billion over 10 years to insure as many as 39 million more people. Gore says he would spend $264 billion over 10 years to cover as many as 15 million more people, mostly children and parents of low-income children.
The Census Bureau says that 44.2 million people, or 16.3 percent of Americans, are uninsured today.
Several independent analysts said the candidates have lowballed their cost estimates. Moreover, both candidates would draw money from the federal budget surplus and might have to scale down their ambitions if the surplus did not materialize.
But a health plan's odds of success are measured in more than money. Five years ago, after a furious national debate, lawmakers shot down President Clinton's massive proposal to insure all Americans. Bradley's plan falls far short of what Clinton would have done, avoiding price controls and other intrusions into the private market. But it is ambitious, and it may antagonize people who fear big changes.
In a dramatic move, Bradley would eliminate Medicaid, the federal-state program for 36 million poor and disabled people.
In its place, he would give money to low-income people to buy their own insurance. Because individuals often pay high premiums when they buy insurance alone, Bradley would allow the public to buy into the federal government's insurance system, the Federal Employees Health Benefits Program. The program offers a range of private plans, and it already serves 9 million federal workers, including members of Congress.
Bradley would also order parents to buy coverage for their children, but it is unclear how this would be enforced. Aides said that hospitals would make sure that children are enrolled in a plan at birth, and that schools, day-care centers, doctors and others could find children who somehow fall through the cracks. But they assume that the subsidies offered under the plan are high enough so that every parent wants to buy insurance and can afford it, a point that others dispute.
Gore, by contrast, avoids big changes to the health delivery system and expands programs that already exist.
By raising the income cut-offs, Gore would make 1 million more children eligible for Medicaid and a relatively new federal-state program called the Children's Health Insurance Program, or CHIP. At higher income levels, parents could buy their children into Medicaid or CHIP at what Gore aides say would be modest premiums.
The most substantive change in Gore's plan is to tell parents that if their children are eligible for Medicaid or CHIP, the parents are, as well. Gore aides say this would insure 7 million more adults while giving an extra nudge to parents who have failed to enroll their children in programs for which they already qualify.
Gore would offer a modest subsidy to adults with no children and to people age 55-65, who often have trouble buying insurance because of their age. Both plans add optional coverage for prescription drugs to Medicare.
''A lot of the debate here is just how expansive you want to be,'' said David Cutler, a Harvard University economist and informal adviser to the Bradley camp. ''The Bradley plan moves closer to universal coverage than the Gore plan. It's also more expensive. Nothing in life is free.''
But some things in life are more expensive than others, and Bradley is more willing than Gore to pay the price.
Children consume few health services and are relatively inexpensive to insure. So are the poorest adults, because in subsidizing them the government offers aid to relatively few people who already have insurance on their own.
Gore focuses on these groups, where the government gets ''real high bang for the buck,'' said Gruber.
But as a plan reaches further up the income scale, Gruber said, it spends more to cover each uninsured person. That is because many more people in the upper classes already have insurance, and it is hard to avoid offering them a subsidy while helping other people in the same income class.
Cutler noted that the Bradley plan subsidizes people who already have insurance, but he said that makes for good public policy. In essense, he said, Bradley is offering a ''well-targeted tax cut'' in the form of the subsidy to low-income people who have reached deep in their pockets to pay for a health policy.
''It's hard to say, `Gee, you valued health insurance and were willing to take $5,000 of your family's $25,000 income to pay for it, and in exchange for that we'll give a subsidy only to someone else,''' Cutler said.
This is what makes the Bradley plan so expensive, said Kenneth Thorpe, a professor of health policy at Emory University in Atlanta. ''Two-thirds of the spending goes to people who already have insurance,'' Thorpe said.
But Gore, on the other hand, risks leaving more poor and near-poor children uninsured, either because they are ineligible or because parents will fail to enroll them, Gruber said. ''Bradley has very few poor people falling through the cracks of the system, but it is very expensive,'' Gruber said.
The effects of eliminating Medicaid are unclear. In its place, Bradley would pay $1,200 for each child to buy a private policy and up to $1,800 for an adult, depending on income. No family would receive more than $5,000.
This means Medicaid beneficiaries would trade guaranteed health coverage for $1,800 that may or may not be enough to buy a private plan. Depending on the state, Medicaid offers no or low copayments for doctor visits and medication, and sometimes free dental or eye care.
According to Thorpe, the least expensive plan available in Boston under the federal employees' system costs $2,272, or $472 more than Bradley's subsidy. Faced with the new cost, some Medicaid beneficiaries would choose to go without insurance, Thorpe said.
Despite the broad ambition of the plans, some people fault Gore and Bradley for failing to control health care costs, which might free money that could be put toward more care. Moreover, the plans generally keep the workplace as the primary place to buy insurance, which is difficult to people who switch jobs, work part-time or do not work.
''We spend more than anyone in the world on health, but the money is going to the wrong place, to 27 health insurance companies that have different systems,'' said Celia Wcislo, president of Local 285 of the Service Employees International Union.
