As adviser to Bill and Hillary Clinton, Ken Thorpe had a close- up view of the fiasco that was health care reform in 1993 and ‘94.

Since that effort crashed, he, like many others, has watched in frustration as costs have soared and health insurance has moved beyond the reach of millions more Americans – 46 million in all.

The Emory University professor of health policy has a clear strategy for attacking the problem – and he’d enlisting influential allies in his cause.

It’s essentially a flanking attack – shifting the focus from the longtime arguments over financing mechanisms and coverage concerns to an assault on the real cost-driver in the system: chronic diseases.

In presentations influencing policies of both Democratic and Republican presidential candidates, Thorpe makes a few basic points:

Government records show 75 percent of health care costs and seven out of every 10 deaths are attributable to chronic diseases such as, diabetes, heart disease and cancer. Obesity, which has doubled in 30 years, is itself responsible for 30 percent of the increase in health costs in that period.

In far too many cases, perhaps a majority, treatment of these diseases is intermittent and inconsistent, and little has been done to prevent them or arrest them in early stages.

“Once you put those numbers on it, the policy implications are pretty clear,” Thorpe said. “You start with prevention and better management of obesity and high blood pressure – not the contentious issues that have dominated the debate.”

Thorpe has now been joined by Mark McClellan, who until recently ran the Medicare and Medicaid programs for the Bush administration, as spokesmen for the Partnership to Fight Chronic Disease, a broad-based national coalition ranging from the American Academy of Family Physicians to the NAACP, the Chamber of Commerce and the YMCA. Affiliates in New Hampshire, Iowa and South Carolina will highlight the issue as the presidential candidates move through those early-voting states.

Already, many candidates are picking up the message. Sen. Hillary Rodham Clinton was using Thorpe’s statistics and analysis on May 24 when she delivered the first of a promised series of speeches outlining her new approach to health reform. It emphasizes disease prevention and cost reductions through better case management, rather than immediate expansion of coverage. Those are important elements also in the plans that her rivals Barack Obama and John Edwards have announced.

On the Republican side, McClellan’s old boss, former Health and Human Services Secretary Tommy Thompson, and former Arkansas Gov. Mike Huckabee, who has written two books on the importance of healthy diets, are already on board, and other candidates’ staffs have been conferring with McClellan.

McClellan says Republicans “don’t want to go to price controls or government regulation, so they understand prevention is the only way to get from here to there,” to lower costs and improve coverage.

To demonstrate that this is not only theoretical, Thorpe and McClellan are proselytizing in individual states. Vermont is their test case. There, a Democratic legislature and Republican governor were at loggerheads over health reform; a veto had stopped the Democratic bill from enactment.

Thorpe helped break the impasse, and the state has now embarked on a coordinated strategy. A three-year effort to link doctors offices and hospitals into an electronic records-keeping system, facilitating better coordination and management of chronic conditions, is beginning now in six towns and will be expanded to the whole state. Along with that, insurance regulations have been changed to eliminate co-pays for routine diagnostic and preventive measures. At the same time, a public health campaign is under way in schools and workplaces to inculcate healthier lifestyles.

Savings from the new program will be used, under the legislation, to subsidize health insurance policies for Vermonters who now lack coverage.

The shift of focus to preventive care and management of chronic diseases offers encouragement to those legislators in both parties who are promoting ambitious schemes to cover the uninsured. By promising reduced costs and better care for the majority of Americans who already have health insurance, this approach perhaps can build support for what still needs to be done to end the shame of America’s broken health care system.