The Great Health Care Debate of 2008 Is Finally Engaged

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I’ve always been skeptical that Hillary Clinton and Barack Obama could really get a health care debate going (though a group of Clinton supporters is trying once again with a new ad in Indiana). The fact is, their two approaches are very similar, and their plans share many of the same features: a requirement that employers cover their workers, big purchasing pools for people who don’t get covered at work, subsidies to help them afford it. Both build on the existing system. Both let people keep the coverage they have, if they are satisfied with it. With so much in common, their biggest difference–Clinton’s so-called “individual mandate,” or requirement that people go out and buy insurance if their employers don’t provide it–is not likely to be the determining factor in deciding how many people will vote.

John McCain has now jumped into the argument with a plan that is, in fact, a radical one. (You can see some good descriptions in the stories that appeared on the front pages of today’s New York Times and Washington Post) But the stories really understate the depth of the philosophical differences that he has staked out between the two parties, or the degree to which McCain’s would be a departure from the system we have now. And you don’t have to take my word for it; I asked an expert. “Now you have a real battle,” says Robert Blendon, professor of health policy and management at the Harvard School of Public Health. “It is one of the biggest philosophical debates we’ve had in a long time.”

Where Obama and Clinton would add to the system in which most people get their health insurance where they work (which is, in many ways, a historical accident resulting from World War II wage and price controls), Blendon explains, McCain’s–which has some of the features of a plan proposed by George Bush in 2007, which didn’t go anywhere in Congress*–actually envisions an entirely new system in which individuals would shop for their own health care coverage, presumably getting a better deal thanks to vastly more competition in the marketplace. “He proposes a vision for the future that doesn’t exist — yet,” Blendon says. “His argument is I’m going to change how this thing works. … In some sense, he has the largest scale what you would call ‘reform’ of all the candidates.”

On the other hand, the assumption underlying the Obama and Clinton plans is the opposite, says Blendon, that “the worst thing that can happen to people is to be by themselves trying to negotiate for insurance. … The solution is protecting people from being out there by themselves” by pooling them together, either through the workplace or in newly created purchasing cooperatives.

As Blendon sees it, the McCain plan and the Democratic plans would each create winners and losers. Under McCain’s approach, employers (who might be able to drop their coverage) would benefit, as might younger and healthier people, and those who live in states where health coverage is relatively inexpensive, like Minnesota. Those who would find their situation worse under the McCain plan include people living in high-cost areas, like New York and Massachusetts, as well as those who are already sick. For the sick and others who are hard to insure, McCain proposes high-risk pools. But Blendon notes that where this approach has been tried, both for health care and for auto coverage, it hasn’t worked all that well, because people end up paying a lot more money for policies that are a lot skimpier. He also notes that McCain’s proposed a refundable $5,000 family tax credit would fall far short of the $12,000 or more that it now costs a family to buy a “reasonably decent” health policy.

In many ways, McCain is moving into far more treacherous political territory as well. As Hillary Clinton learned the hard way in 1994, it is dangerous to propose pushing people who are reasonably satisfied with their current coverage into a different system. (That’s why every time she discusses her current plan, she starts by telling people that if they like what they have, they can keep it.) “Do people who have insurance in the workplace really want ot take the risk of moving out?” Blendon asks. “The history of the health care debate is that middle-income people in this country are risk averse.”

But at least we finally have something to argue about.

*By popular demand of our commenters.