The good news for those who care about health care is that
the issue is rising again on the national agenda. If we have a
big debate about health in the presidential campaign and if it
is a factor at the polls in 2008, it will help create a
mandate for the new president and Congress to make health care
a priority in 2009.
But the real health care debate has been delayed by the
focus in the primaries on the differences on health between
candidates in each party, especially the differences between
the plans put forward by the leading Democratic candidates.
While the differences between the candidates' plans can
mean a lot to experts, they mean much less to voters. Senator
Edwards described them as "in the weeds," and our tracking
polls have consistently shown that differences
between the candidates' plans have not had an appreciable
impact on voters in the primaries. In general, the
primaries so far have not been driven by differences on
issues, but rather by the perceived differences in the
leadership qualities of the candidates. The health care
debate that will come next in the general election is much
more important because it’s about the truly profound gulf
between Democrats and Republicans and the political right and
left about the future directions our health care system should
take. These are the differences that have paralyzed Washington
on health reform for years and will continue to pose a
formidable obstacle to compromise when a new President and
Congress consider health reform legislation in 2009.
Health08.org contains
a unique library of candidates' statements on health reform,
revealing not just the details of their plans, but what they
emphasize most consistently about health reform and their
vision for the future of the health care system. A look
at the key buzzwords and phrases used by
candidates is an entertaining and quick way to
reveal the key differences between the two sides.
Watch
the key buzzwords and phrases used by the candidates.
In listening to candidates at a series of presidential
candidate forums in our Barbara Jordan Conference Center and
sifting through the hundreds of hours of speeches, debates,
and documents by Presidential candidates about health policy
we have compiled on the web, here are three critical
differences between the parties that set the stage for the
next health reform debate.
First, there is a basic difference on whether guaranteeing
universal or nearly universal health insurance coverage should
be the primary goal of health reform. Democrats consistently
say it should be, though the leading candidates’ plans differ
somewhat on how to get there and whose plan represents a
better approach. Republicans do not have universal coverage as
their overarching goal. They believe it requires too big a
role for government to guarantee universal coverage and will
cost too much to pay for it. Instead, they want to make
coverage more available in the private marketplace and give
people a tax break to help those who want it afford it. The
top priority they emphasize is to create a more efficient, and
in their view, more affordable private health insurance
marketplace based on individual choice and competition. This,
they believe will expand coverage, but guaranteeing coverage
for all is not their main goal. This difference reflects
the greater priority their base gives to controlling costs
over expanding coverage, as documented repeatedly in the tracking
polls that Molly Brodie, who heads our polling group, and
her team conduct at the Foundation.
Watch
the candidates discuss the goals of reform.
A second big difference is in how Democrats and Republicans
would organize the health insurance system. The leading
Democratic candidates emphasize building on the current
employment-based health insurance system and public programs.
They call for greater regulation of insurers, for example
requiring them to accept all applicants and limiting their
administrative costs. The Republicans, by contrast, prefer a
system in which more people purchase insurance themselves in
the individual marketplace, with fewer requirements on
insurers. While Democrats would spend more to get to universal
coverage, and their plans are perceived as more expansive as a
result, it is actually the Republicans who envision bigger
changes because they want to see more people get their
insurance in the individual marketplace rather than through
the workplace where most Americans get it today. No
leading candidate on either side is proposing scrapping the
current health care system, only Congressman Kucinich proposed
that, but while the Democrats have the bigger plans, it is the
Republicans who envision a more fundamental transformation of
the health insurance system, a difference which has been lost
in the discussion to date.
Watch
the candidates discuss their differences on how to organize
the health insurance system.
Third, there is also a fundamental difference in what the
two sides see as the basic purpose of health insurance.
Democrats favor comprehensive insurance with front-end
protection, which in their view encourages more preventive
care and protects people better from financial costs of an
illness. Republicans generally promote plans with high
deductibles on the front end and catastrophic protection on
the back end, coupled with tax-preferred savings accounts
people would use to pay for routine care. They believe this
will encourage people to become more prudent consumers of
health care and use less health care overall. Whether
high deductible health plans with savings accounts are a
forward-looking reform that will introduce market incentives
and lower costs as advocates claim, or represent skimpier
insurance surrounded by market rhetoric as critics believe, is
an important question to debate and study as these new forms
of insurance enter the marketplace. My purpose here is to
characterize differences, not to referee these
debates. There is no question, however, that the
difference between the parties on the very nature and purpose
of health insurance is a fundamental one that needs to be
elucidated for voters.
Watch
the candidates discuss their view on the nature and purpose of
health insurance.
When we get beyond the
primaries, the two candidates will lay out their multipart
health reform plans, the media will pick apart the details of
the plans, and the ads and the charges and counter charges
will fly. All of the rhetoric, from “shared
responsibility” on the one side to "personal responsibility"
on the other side, will sound appealing to many, and the
public again will be confused. Of course the candidates should
be accountable for the substance of the plans they propose,
but details will matter much more when there is a legislative
debate in 2009. Moreover, with presidents having learned the
hard way about the limits of a "my way or the highway"
approach to health reform in 1993, the debate this time may be
driven as much by ideas hatched in the Congress as by the
President and the Executive Branch.
If we are to have a meaningful debate about health in the
campaign, the bigger challenge will be to look beyond the
details of plans proposed in a political campaign and debate
the basic, very fundamental differences in priorities and
direction for our health system being offered by the two
sides, which are evident from the video clips from the
campaign trail. This is especially a challenge for the news
media, which often sees its role as exposing the juiciest
details of the candidates’ plans rather than explaining more
fundamental choices. By focusing on the forest as well
as the trees, we could have a health care debate that will
engage the American people rather than confuse them, and set
the stage for the even more difficult task of
bridging health care's ideological divide in the Congress in
2009.
--Published February 27, 2008