Candidates Write Their Prescriptions
Democrats offer ideas to reform the healthcare system
Universal healthcare means never having to say, "I'm sorry-you're not covered."
The three Democratic candidates for the 2008 presidential nomination who have offered proposals to reform the nation's healthcare system—former Sen. John Edwards, Sen. Hillary Clinton, and, last week, Sen. Barack Obama—are all to varying degrees promising Americans, 45 million of whom currently have no insurance, that they won't have to fear hearing those words again.
Healthcare is one of the chief worries of most Americans. Even though the election is more than a year away, how the candidates propose to fix what many perceive as an increasingly stingy and unaffordable system is already a hot topic on the campaign trail. Moderate voters will be a key constituency in 2008, according to pollster John Zogby. These voters want universal healthcare, but they don't want it delivered in a big government package. "Tops among the Democratic voting bloc is the idea that the era of big government is over," he says. "The results may be big, but the process shouldn't be grandiose." From that perspective, he says, the Democrats have all come forward with relatively modest proposals that could be equally well received.
The three plans put forth so far are striking more for their similarities than for their differences. (Clinton, who famously presented a far-reaching healthcare plan during her husband's first term as president only to watch it flame out, has yet to offer many specifics on how she would reform individual healthcare, focusing instead on broad systemic changes.) "They're all proposing a set of policy tools that experts agree have the potential to expand coverage," says Linda Blumberg, a health economist at the Urban Institute in Washington, D.C.
Universal access. True enough, but consumers don't think in terms of policy tools. They want to know three things: How am I going to get or keep my insurance, how am I going to pay for it, and what happens if I am or become sick?
On the question of getting and keeping insurance, all three candidates propose some version of universal access to healthcare, though they differ on whether everyone should be required to have it. People would be able to keep the coverage they have if they want, but they'd have other options, too. Edwards and Obama would both create purchasing pools through which people could buy comprehensive, affordable health insurance, and they'd expand public programs like Medicaid and the State Children's Health Insurance Program to cover more people. But the candidates diverge on how they would go about providing coverage. Edwards favors making health insurance mandatory for virtually everyone. Clinton generally advocates covering everyone, though she hasn't proposed a mandatory system. Obama, on the other hand, would require health insurance for children only.
Experts agree a comprehensive mandate is probably the only way to achieve universal health coverage. It also helps keep health insurance rates lower, because insurers don't worry they're going to get stuck with too many sick people. But Obama's approach doesn't sit so well with some experts. "I'm just stunned that Obama chose not to have a mandate to try to make the market more efficient and to get better coverage," says Len Nichols, director of the health policy program at the New America Foundation in Washington, D.C.
Affordable healthcare seems like an oxymoron these days, but the candidates hope to change that. Edwards proposes tax credits on a sliding scale to help middle- and lower-income families buy insurance. Obama wants subsidies for families that don't qualify for Medicaid or SCHIP. All three candidates agree on market reforms that would guarantee coverage at a fair premium for everyone, regardless of any health problems, which insurers currently use to either deny coverage outright or raise premiums to a level that makes them unaffordable for many.
Recognizing that approximately 80 percent of healthcare dollars are spent on the roughly 20 percent of people suffering from chronic illnesses and other serious medical problems, it's no surprise that all three candidates are pushing care coordination for people with chronic conditions as well as focusing on preventive care to improve the overall health of the population. But with an aging population—and one that is getting fatter all the time—it's unlikely that can happen quick enough to reduce costs in the near term."It's a real leap from saying this should be the emphasis to actually changing this in the system," says Paul Ginsburg, president of the Center for Studying Health System Change.
High tech. All three candidates offer the shopworn comments about the need to improve the quality of healthcare technology. It has long been accepted that better technology could go a long way toward improving patient care. Just ask anyone who's had a record of a diagnostic test sent to the wrong facility or a prescription filled incorrectly because of a physician's illegible handwriting. But this, too, is easier said than done, and providers may be reluctant to make upfront investments in such technologies when compatibility standards and other issues haven't been resolved.
It's still the early days. None of the Republican candidates nor the other Democrats have put forward healthcare proposals to date. But that should come, say experts. "For the candidates, it's the price of admission to have a health reform proposal," says Ginsburg. "That's a reflection of how much more interest there is in this topic than in the last election." For voters who care about healthcare, this is a welcome remedy.
This story appears in the June 11, 2007 print edition of U.S. News & World Report.