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March 7, 2008
Now that it appears the Democratic presidential contest will keep going for some time, health care will continue to be a major topic of debate. While most of the disagreement between Sens. Hillary Clinton and Barack Obama has focused on universal coverage -- and particularly an individual mandate -- that dispute is actually overshadowing how many similarities there are between their two health policy proposals.
The sooner that voters focus on the larger picture, the better informed their decisions can be. There are a number of provisions in both of their plans which are not controversial, such as a greater emphasis on using health information technologies, offering a choice of health plans, better prevention and chronic care management, etc.
But here is a partial list of what Sen. Clinton and Sen. Obama are proposing that reveals their visions of a much larger role for government in our health sector. They both would create new health care purchasing arrangements and propose:
- Requiring insurers to charge basically the same premium to everyone regardless of age, gender, or occupation, called community rating
- Requiring insurers to offer coverage to anyone who applies through guaranteed issue and prohibiting denials for pre-existing conditions
- Requiring insurers to offer health insurance that is at least as generous as the comprehensive coverage available to members of Congress
- Requiring employers to contribute to the health coverage for their workers through a "pay or play" mandate, with small business getting added help to offset costs
- The government would repay businesses for some of the catastrophic costs of employees with large medical expenses, providing certain conditions are met, a proposal similar to one offered in 2004 by Democratic presidential candidate John Kerry
- Opening the Federal Employees Health Benefits Program to millions more workers and setting up other regulated health insurance purchasing exchanges
- Expanding Medicaid and the State Children's Health Insurance Program
- Allowing people to buy in to Medicare, thereby setting up competition between a taxpayer-subsidized program with federal pricing and policing authority and private health plans
- Curtailing private competition in Medicare by scaling back payments for Medicare Advantage and allowing the government, rather than private companies, to negotiate prescription drug prices for the Medicare drug benefit
- Allowing prescription drug importation from abroad, which means importing other countries' systems of price controls (as Sen. McCain also has proposed), and placing new controls on prescription drug prices
- Greater government involvement in determining the comparative effectiveness of medical treatments and requiring doctors and hospitals to practice according to its evidence-based protocols.
Sen. Clinton has criticized Sen. Obama for proposing a plan that does not have universal coverage as its central goal, even though he would begin with a mandate that all children be covered.
This dispute is important, but it should not obscure the many, many other provisions in their plans over which there is little debate but which would inject a much larger role for the federal government in health care financing and delivery.
Most of the Republican presidential candidates' plans were organized around the idea of moving more power and control over health insurance and health care decisions to patients, as I described in my recent Wall Street Journal article. Because there was little debate in the GOP contest over health care, the issue received little attention. But to prepare for the general election, Sen. McCain must do more work to refine and develop his plan.
There will be much more time to analyze all of these provisions in the coming months, but it's important to see that there are two very different approaches here to health reform.
The question for voters this fall will be whether they think that the government will be able to inject greater efficiency and choice into the health sector or whether we should have a new approach that puts doctors and patients in charge and provides new incentives for competing plans and providers to offer more affordable care and coverage.
Grace-Marie Turner
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