Government costs. Clinton's plan, with an estimated $110 billion annual price tag for the government, would require everyone to have coverage. Obama would make coverage mandatory only for children. His plan would cost roughly $50 billion to $65 billion a year. "If it's accessible and affordable, they'll buy it, independent of whether they have to buy it or not," says David Cutler, an economics professor at Harvard who's advising the Obama campaign. Not true, argues the Clinton camp. Without a mandate, some people, especially young, healthy ones, are going to skip signing up, and their participation is key to balancing out the higher healthcare costs of those who are sick. Who's right? It's not clear, though economists have generally sided with Clinton on this issue.
So far, voters have heard primarily about the two Democrats' plans, since healthcare isn't traditionally a central issue for Republicans. According to the Kaiser Family Foundation's March health-tracking poll, healthcare ranks second among the issues Democratic voters want the candidates to address, right behind the economy. For independent voters, it's the third-ranked issue, and among Republicans, it's in fourth place.
Now that McCain is the presumptive nominee, people are beginning to pay closer attention to his healthcare plan. Its centerpiece is a proposal to eliminate the tax break that employees currently get on their employer-sponsored health insurance benefits. Instead, McCain would give annual tax credits of $2,500 to individuals and $5,000 to families to put toward buying insurance through their employer, on the individual market, or from other organizations. He favors insurance competition, tort reform, and changes in the way that providers are paid as ways to contain costs.
What he doesn't favor is requiring insurers to cover all comers or mandating everyone to have insurance. Many specifics, including the estimated cost of the McCain plan, remain unclear. "There are lots of details to be filled out," says Tom Miller, a resident fellow at the American Enterprise Institute who is an outside adviser to McCain on healthcare. McCain is expected to offer more information about his healthcare proposal at the end of April. But his plan has already come under fire because it would encourage coverage in the individual, non-job-based insurance market, where people buy their own policies from brokers or insurers. Regulation in this market is much lighter, and insurers can cherry-pick the best prospects. "His approach requires an individual product that everyone can get," says Robert Laszewski, a Washington health policy analyst. "But these [plans] are most expensive for the old, and if you're sick, you're not going to get coverage at all."
Elizabeth Edwards, breast cancer patient and the wife of John Edwards, has criticized McCain's plan because it wouldn't guarantee coverage for people like her or McCain himself, who has been treated for melanoma. McCain adviser Miller says there are a number of options under consideration, including giving bigger subsidies to the sick or making some sort of "high-risk pool" insurance coverage available to people who can't get coverage elsewhere. McCain's free-market approach is probably less appealing to voters of all stripes than are the Democrats' proposals, say experts. But the Democratic plans to cover everyone are vulnerable as well. Republicans will charge that big-spending Democrats are proposing to sink up to $100 billion a year into a healthcare program while paying scant attention to cost containment. "McCain will say it's like loading more people onto a sinking ship," says Laszewski. Democrats also risk charges that their insurance mandates are too tough on business, especially during shaky economic times, says Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health. "People get very sympathetic toward companies during a downturn."
Of course, if the economy continues to slide, voters may generally be unenthused about major reform, say experts. The challenge then is to make it clear that healthcare is an economic issue. "For this to fly, it has to be part of a broader economic package that addresses everyday economic concerns that people have," says Drew Altman, president and CEO of the Kaiser Family Foundation. "The rhetoric will have to shift, and so will the packaging." Stay tuned.