Health Care Conundrum
On a global level, the philosophical differences between Sens. McCain and Obama shine through on this issue perhaps more than any other in the realm of domestic policy. McCain, as he is wont to do, favors free market solutions to the issue, with government more than anything else acting as the facilitator of reform. Obama, by comparison, relies mostly on the expansion of government programs and increased regulation of the private health care industry (It is also interesting to consider that Sen. Hillary Clinton's health care proposal was even more comprehensive than that of Obama, one of the only major policy differences that separated the two Democratic heavy weights.). A contrast of their policies follows, and it promises to get complicated, so please keep this basic framework in mind.
The debate begins with the 47 million Americans who are uninsured. Included in this number are the estimated 12 million illegal immigrants residing in this country, along with a number of single mothers who are eligible for Medicaid. If these numbers are subtracted, we are still situated someone in the vicinity of 30 million without coverage, or 1 in 10 Americans, a number that both McCain and Obama consider unacceptably high.
Let's begin by looking at the heart McCain's reform proposal. His plan starts with the premise that patients, not insurance companies, should have more control of their health dollars. He seeks to remove barriers to access, allowing portability across state lines, even different jobs. As of now, employer-provided health care plans are not subject to taxation on the employee's end. McCain would end this "subsidy," and offset it with tax credits of $2500 for individuals and $5000 for families in order to purchase their own insurance, regardless of whether their employer provides it or not. In the case where the entire credit is not exhausted by the costs of insurance, the balance would be deposited in health saving accounts first pioneered by current President Bush.
By comparison, Obama would offer the same health care plan available to federal employees to those individuals without health care. This falls short of the universal coverage advocated by Clinton, for it still allows individuals to remain without health care if they so choose. Access to the plan would be universal, benefits "comprehensive," and premiums, co-pays and deductibles "affordable." Those unable to meet these costs would be eligible for federal subsidies. Like McCain, Obama pledges that his plan will be portable across jobs. Unlike his Republican opponent, Obama requires employers who do not offer health care to contribute a percentage of payroll receipts to the national plan.
Obama does allow the private health care system utilized by most Americans to remain in place. He proposes to create the National Health Insurance Exchange, a regulatory body, to oversee private insurers. He pledges that it would keep costs at or below that of the federal program, require reporting of pricing for the sake of consumer comparison, and mandate accessibility to all comers.
McCain proposes a guaranteed access plan of his own, but its power would be state, not nationally-based. He pledges to work with governors to develop a best-practice model that may be replicated across the nation, holding up a nonprofit corporation who would work with private insurance companies to offer coverage to those with preexisting conditions, maintaining reasonable costs, and offering subsidies when necessary. McCain envisions economies of scale
as multiple states join together to pool risks.
The senior Arizona senator also addresses the cost side of the health care equation, recognizing that health care costs will represent 20 percent of our Gross Domestic Product within the next decade, not to mention the fact that Obama (and Clinton for that matter) exempt many small business from the mandates of their health care plans. McCain's cost controls center on cheaper prescription drugs via re-importation (Obama is in agreement here) and greater use of generic drugs; prevention and early intervention for chronic diseases that consume 75 percent of current health care costs (Obama echoes this); greater use of electronic records (Obama seconds this, too) to root out mismanagement and medical errors committed under the auspices of Medicare and Medicaid; and overall, greater transparency from the provision to health care to payment for its services (again, Obama and McCain are on the same page). McCain also adopts the age-old conservative banner of tort reform, pledging to end "frivolous" lawsuits.
Obama, by comparison, also pledges malpractice reform, but instead of limiting payouts for lawsuits, he would restrict premiums charged by malpractice providers. His proposed measures of cost control are many, including those areas above where he is in basic agreement with McCain. He also promises to reimburse employers for the incidence of costs for catastrophic care so long as the money is used to lower employee premiums. Like McCain, Obama takes on the pharmaceutical industry, but he also directs his attention toward private insurers, pledging that he will force them to devote a fixed portion of their premiums to patient care, not profits.
Additionally, Obama addresses the quality side of the equation through more intense government regulation of the health care sector. This includes reporting on preventable medical errors; incentives for quality care, not merely the volume of care provided; and the elimination of inequities that surface through health care provision.
Obama proceeds to blaze new paths in areas tangential to health care, including support for biomedical research, AIDS in Africa, individuals with disabilities (specifically those with mental illness), and autism. Interestingly enough, McCain also delves into the latter topic, citing his continued advocacy of the issue, including his co-sponsorship of the Combating Autism Act of 2006. He also trumpets his support of The Health Insurance Portability And Accountability Act of 1996, legislation that tackled, at least in part, discrimination for preexisting conditions. Like McCain, Obama boasts of his leadership on health care issues, including his support of expanded health care coverage for children and adults as an Illinois legislator, and his co-sponsorship of SCHIP's reauthorization in 2007 as a U.S. Senator.
In the end, the reality is that the aforementioned details probably do not matter, at least as this juncture. Rather, the broader policy commitments should demand our attention, for while presidents may lead on this issue, Congress will also have its hands in the mix from the get-go (see the failed 1993 battle for national health care). Moreover, Harry Truman was the first president to stand in favor of national health care. He was followed by Lyndon Johnson, Jimmy Carter and Bill Clinton. All failed, yet Johnson did create Medicare and Medicaid, and universal coverage remains a pipe dream.
Obama promises a lighter version of the plan forwarded by Clinton to Congress in 1993, and the political climate may be more favorable to passage than ever before. The reality, however, is that McCain's piecemeal approach is more typical of past reforms and perhaps more digestible for practitioners in the polarized capital. The winner of this year's White House sweepstakes will offer different medicines to cure our crippling health care crisis. In this case, the patients must chose the preferred path for recovery.