Where Do the Presidential Candidates Stand on Health Care?

Ask Americans if their fellow citizens should have access to health care, and they will shout a resounding yes. Ask them what they are willing to pay or give up so that others may have such coverage, and most whisper-nothing.

This is because middle-class voters are accustomed to getting American-style on-demand health care at a fraction of its actual cost. Despite such contradictory thinking, health care is a hot issue in the 2008 presidential race because of broad frustration with the current system, steadily rising costs, approximately 47 million uninsured people, and concerns about the employer-based insurance system’s future.

Both Senators John McCain (R-AZ) and Barack Obama (D-IL) propose radical changes to the health care system, each demanding a different brand of sacrifice. In essence, Mr. Obama would add new entitlements costing at least $155 billion, a Medicaid- or Medicare-like plan for anyone who wants it, and expanded State Children’s Health Insurance Program (SCHIP) and Medicaid. Mr. McCain’s market-based approach would tax employer-sponsored health care benefits, offset by a $2500 tax credit for individuals and $5000 for families, and open the insurance market to competition.

The Republican’s plan is consumer-driven: Make people aware of how much health care costs, and hope they spend their dollars wisely. Executives with gold-standard plans and millions of union members who traded generous health benefits for wages will be taxed on their health benefits’ value above the allowable credit. They don’t like it. The Democrat’s proposal to add costly new entitlements to Social Security, Medicare, and Medicaid entitlements already straining the federal budget faces stiff opposition by taxpayers and legislators.

As for physicians, Mr. Obama’s entitlements most likely would reimburse providers on Medicaid-like schedules. Mr. McCain’s consumer-driven approach might encourage competitive pricing and comparison shopping. Either way, Davis Liu, MD, MBA, a Permanente Medical Group of Northern California family physician, sees nothing for physicians in either plan. He points to the danger of cutting reimbursement to providers: When United HealthCare bought PacifiCare, they cut reimbursement by 30 percent. Providers left, saying the reimbursement squeeze was too much. A big bully muscling you with volume doesn’t often work with doctors.

Wishful Thinking on Saving

Expanding the number of insured people, whether through Mr. Obama’s universal mandate or Mr. McCain’s market-based reforms, is predicated on anticipated cost savings on $2 trillion annual spending, now consuming 16% of gross domestic product (GDP). Both candidates spout Mom and apple pie rhetoric about cost-cutting measures such as reducing unnecessary tests and procedures, more preventive care, disease management and care coordination, patient safety, quality improvement, and widespread adoption of electronic medical records. None of these are low-hanging fruit.