Republican, Democratic Health Care Proposals Focus on Insurance

The health care proposals put forth by the leading presidential candidates may differ sharply in their approaches to health care reform, but the common factor among them is that none of the plans represents a profound or fundamental change to the nation's health care system.

"Neither party is focusing on fixing the structure of health care, so it would be a big mistake to think this is a debate around structurally re-changing health care," said Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard School of Public Health in Cambridge, Mass. "It is a debate about offering people more insurance choices, better insurance choices or some insurance choices. It is not a debate about restructuring the health care system."

"The idea that we are going to rebuild the health care system in one sweeping piece of legislation is not on this election's agenda," added Blendon, who directs both the Harvard Opinion Research Program and the Henry J. Kaiser National Program on the Public, Health and Social Policy.

The health care proposals espoused by Democratic candidates Sen. Hillary Clinton, D-N.Y., and Sen. Barack Obama, D-Ill., are more focused on covering as many of the 47 million uninsured U.S. residents as possible through a series of mandates and requirements that would lead to universal or near-universal coverage. The proposal put forth by Republican candidate Sen. John McCain, R-Ariz., however, is more about providing an array of health insurance choices at cheaper rates through market and tax reforms.

"The debate between Clinton and Obama is whether each of their proposals would cover the 47 million uninsured or if one of their plans has slipped by 10 or 15 million," said Blendon.

McCain, by contrast, has never said how many U.S. residents his plan will cover. He has focused instead on helping individuals obtain less expensive insurance or buy their own insurance by making the marketplace work better for people with existing coverage and giving some aid to people without insurance, Blendon said.

McCain's proposal is based on three concepts -- no mandates on business, no mandates on individuals, and no new taxes. "Whatever reforms are made, they are not going to affect those three areas," Blendon said of McCain's proposal.

McCain's plan would provide a tax credit of $2,500 for individuals and $5,000 for families for the purchase of insurance. It also would require any state receiving Medicaid to develop financial risk-adjustment bonuses for families with low incomes or high health care costs to supplement tax credits and Medicaid funds, according to a side-by-side analysis of the health care plans conducted by the Kaiser Family Foundation. McCain's plan also seeks to end the favorable tax treatment of employer-sponsored insurance to give individuals more options to buy insurance, according to the Kaiser comparison.

On the Democratic side, Clinton's plan would require every individual to carry insurance while requiring large employers either to provide an employee plan or contribute to the cost of coverage. Most small employers would not have to offer plans or contribute to coverage costs, but they would be given incentives to do so, according to the Kaiser analysis. Clinton's plan also would make private and public plan options available for individuals through a program operated through the Federal Employee Health Benefits Program.

Obama's plan, meanwhile, requires all children to have health insurance, but not all adults. It also would require employers to provide employee health benefits or contribute to the cost of a new public program. In addition, Obama's plan would create a National Health Insurance Exchange for small businesses and individuals without access to other public programs or employer-based coverage, according to the Kaiser summary. Both the Obama and Clinton plans would increase coverage through expansions in Medicaid and the State Children's Health Insurance Program.

The current Democratic and Republican plans already have triggered debate about the role of the federal government in providing health care coverage, but that debate still essentially revolves around how to best provide health insurance coverage, not about how to make wholesale or systematic changes to the health care system. That's an important distinction from the health care debate of the early 1990s.

Health care reform, as well as health care coverage, are key issues in this election, according to AAFP President Jim King, of Selmer, Tenn., who noted that "candidates also need to consider health care reform." The Academy and family physicians can help the candidates understand the importance of health care reform -- not just health care coverage -- by

"There are a lot of good things about the current health care system we want to continue," King said. "But there are a lot of changes we need to make, including incorporating the patient-centered medical home into our system of care. We need to create a system in which primary care physicians work with their patients to get them the services they need and the right care."

None of the candidates, however, has provided detailed or comprehensive plans for reforming the nation's health care system. "We have to be realistic," said FP Richard Wender, M.D., alumni professor and chair of the department of family and community medicine at Thomas Jefferson University in Philadelphia. "No candidate is going to put out an in-depth plan until he or she is elected. An in-depth plan that is going to address all the obstacles we are going to address, all the obstacles we are going to face, is going to have some very difficult, challenging concepts." The candidates' proposals reflect a general direction and an overall philosophy, not a concrete plan, he added.

Like many analysts, Wender identified accelerating health care costs as the "fundamental driver" of the nation's health care system. "It is rising expenditures that are pricing employers out of the health care market, pricing individuals out of the health care market and fueling the steady rise in the uninsured," said Wender. "Whatever system we put into place must reduce the rising expenditures on health care,"

"That is where the patient-centered medical home can be of use," said King. "Research has shown that a health care system based on primary care provides better health care quality at lower costs."

Incorporating the patient-centered primary care model into health care reform would lead to more use of electronic health records, or EHRs, and better care for patients with chronic conditions, something that the candidates acknowledge could reduce costs, said King.

For example, Clinton's health care plan would adopt a "paperless health information technology system," as one way to reduce costs, while Obama's plan would invest $50 billion toward adoption of EHRs and other health information technology. McCain's plan would contain costs by adopting malpractice reforms that "limit frivolous lawsuits and excessive damages," according to the Kaiser analysis.

In addition, each of the plans calls for greater prevention efforts and better management of chronic diseases, proposals that, if enacted, would shift the nation's treatment paradigm from an acute care to a preventive care model. This strongly suggests a greater role for primary care, but without specifics, it is difficult, if not impossible, to determine how primary care would fare under the plans.

"The evidence is overwhelming that a primary care-based health care delivery system provides higher quality at lower costs," Wender said. But to make primary care a cornerstone of any health care plan, policy-makers will have to change the nation's payment system to encourage and strengthen the primary care infrastructure.