In an article published last week in the New England Journal of Medicine, social medicine and health policy expert Jonathan Oberlander critiqued the health-care plans of the leading Democratic and Republican presidential candidates.
Oberlander’s findings on the Dems:
- The three front-runners – Sen. Hillary Clinton [D-NY], Sen. Barack Obama [D-Ill.] and former Sen. John Edwards [D-NC] – all have very similar plans. Their goal is to provide coverage for all or nearly all of the 47 million currently uninsured Americans.
- The Democratic plans all rely on a “play-or-pay” employer mandate to move toward universal coverage, requiring businesses to either offer workers insurance or pay a tax.
- “Employer-sponsored insurance has been a cornerstone of the U.S. health care system since the 1940s and now covers about 160 million nonelderly Americans. Play-or-pay models enable reformers to finance universal coverage mainly through employer payments rather than creating a publicly funded system that would require new broad-based taxes.”
- Medicare would be retained, and Medicaid and SCHIP would be expanded to cover more low-income Americans. In addition, the Clinton, Edwards, and Obama plans all create a new public insurance plan that would be available alongside private options.
- The top three candidates avoid any explicit budgeting of health care spending or centralized cost controls, instead offering a politically friendlier assortment of cost-saving measures, including electronic medical records and a focus on prevention and disease management. These measures may be good health policy, but their capacity to generate large savings is uncertain, and they are unlikely to restrain health care spending for long.
- The Democratic plans are financed largely by rolling back tax cuts adopted by the Bush administration for families making more than $200,000 (Edwards) or $250,000 (Clinton and Obama) annually.
- “Democratic presidential candidates are, in essence, betting that the public would rather spend federal money on covering the uninsured (and making coverage for the already-insured more secure and affordable) than on extending tax cuts for the wealthy.”
- All of them contain provisions designed to reassure insured Americans that they can keep their current coverage if they want to.
Oberlander’s findings on the Republicans:
- None of the top three candidates – former Massachusetts Gov. Mitt Romney, former New York Mayor Rudy Giuliani and Sen. John McCain [R-Ariz.] – has introduced a health plan as detailed or comprehensive as any of the Democrats’.
- The leaders generally favor incremental expansions of insurance coverage and changes in tax policy to improve access and control costs.
- Giuliani and McCain would offer tax credits to Americans purchasing their own insurance. The aim is to shift enrollment from employer-sponsored into the private market. Romney, on the other hand, would have the federal government work with the states to form a health solution, and his tax credits would also allow individuals to purchase private insurance.
- All the Republican plans call for deregulation of insurance markets, investments in health information technology, medical malpractice reform, and expansion of health savings accounts (tax-preferred accounts that can be used to pay for medical expenses in conjunction with high-deductible health insurance).
- “Without more details, it is difficult to assess the plans’ potential impact, but their incremental measures are unlikely to substantially increase health insurance coverage or effectively control costs.”