October 08, 2007
Monday

In the face of polls that consistently cite health care as the voters' leading domestic concern, presidential candidates in both parties have offered a welter of proposals on how they would extend availability and contain costs, which now consume an estimated 16 percent of the gross domestic product.

Leading Democrats want to provide coverage to the estimated 47 million Americans who lack health care of any kind. The Republican candidates argue that the way to a better health care system lies in a greater role for the free market, not a greater role for the government.

Democrats have been willing to project overall price tags on sometimes ambitious plans, but even the most detailed blueprints leave unanswered important questions on how they would work in practice.

Candidates of both parties talk optimistically about driving down costs through systemic changes such as preventing medical errors, better record-keeping and steps to enhance preventive care and the spread of optimum treatment practices. But few health care experts see any realistic possibility for a real reduction in the price tag of a system that is as central to the health of the economy as it is to that of individuals.

"I realize that they are running for office and outlining directional strategies, and often, during an election, that's as far as anyone is willing to go," said Rosemarie Greco, director of Pennsylvania's Office of Health Care Reform. "I would like a more concrete understanding of how they intend to proceed."

Those nitty-gritty answers are elusive.

Former Sen. John Edwards, of North Carolina, for example, staked out the health care issue early with a detailed plan for universal care. It asserts that its reforms would allow uninsured families to purchase coverage "at an affordable cost," and enable employers to "find it cheaper and easier to insure their workers." But no specific numbers are attached to those promises.

Former New York Mayor Rudy Giuliani proposes a system of tax deductions and credits to allow individuals to purchase coverage. But it would be a leap in the dark to see whether such tax breaks would be enough to provide coverage for most people, including those with chronic health problems.

Sen. Hillary Rodham Clinton, of New York, has called for a refundable tax credit to limit premiums to a percentage of income. But at this point, the percentage is undefined, so, however valuable it is as a concept, its worth to individual Americans is tough to assess.

While there has been much debate, chiefly on the Democratic side, on the plight of the uninsured, last week's strike and eventual agreement at General Motors highlighted another profound challenge for the nation's health care system, and one that has been the focus of less attention on the campaign trail.

GM's $51 billion in unfunded promises for health care is just one example of the unfunded liabilities of firms and governments across the nation. Pennsylvania, for example, projects an unfunded liability for retiree health care of roughly $14 billion.

Mrs. Clinton's health care plan includes a Retiree Health Care Legacy Initiative designed to give certain businesses and public health care systems some measure of relief. The plan discusses tax credits to defray part of the costs of insuring care for catastrophic illnesses. A spokesman for the Clinton campaign said the benefit would be extended to companies with a high ratio of retirees to workers.

It would also include a sunset provision, designed to cope with the enormous but temporary demographic challenge posed by the bulge of baby boom retirees. But the campaign could not explain a precise level or mechanism for the tax credit. The plan is meant to apply to certain public sector retirees as well but how the tax code could be used to help public systems is not clear either.

Some of the highlights of the health care concepts discussed in the campaign so far.

The Democrats:

Sen. Hillary Rodham Clinton's is the latest of the health care proposals unveiled by the Democratic candidates. She estimates its cost at $110 billion. Like Former Sen. John Edwards, she would demand that every American have health insurance. She would ask that employers either cover their workers directly or pay for their costs under one of the other options of her plan. To soften the requirement for smaller businesses, she would offer a tax credit for coverage. Individuals could enroll in private insurance programs patterned on the options given to federal employees or join a new public insurance program modeled on Medicare.

Edwards has called for a similar insurance mandate for employers along with a coverage mandate for individuals. Although he maintains that his plan would ease the costs of covering employees, he does not call for the same tax credit mechanism for small business. His option for coverage include new "health care markets" -- large purchasing pools that would allow businesses and individuals to take advantage of economies of scale in obtaining coverage. He estimates that his plan would cost between $90 billion and $120 billion.

In addition to private insurers, the new health care markets would include a public coverage option modeled on Medicare. Over time, if enough individuals and employers end up opting for the Medicare clone, it could evolve into something resembling the single-payer system in place in many other countries.

None of the Democrats, however, with the exception of Rep. Dennis Kucinich, is proposing a near-term overall shift to a single-payer system.

Like Edwards and Clinton, Sen. Barack Obama, of Illinois, would mandate employer contributions for the cost of health care. He would require coverage for all children but not for adults, although he argues that the cost savings he'd promote at the same time would have the effect of moving the country to universal coverage. In a feature common to the Democratic plans, he would demand that insurers be barred from refusing or terminating coverage because of medical history. Obama would create a so-called national insurance exchange designed to make it easier for consumers to shop among private plans, along with a public option modeled on choices available to federal workers. Obama has projected his plan's cost at between $50 billion and $65 billion.

The Republicans

Former Massachusetts Gov. Mitt Romney is the Republican most identified with health care reform. As governor, he was one of the architects of an innovative Massachusetts program that mandates coverage while creating a "connector" to provide information about private plans along with a state sponsored program for basic coverage. The plan has attracted national attention. Romney, however, does not want to use it as a model for the nation. Rather, he has called for the 50 states to be the incubators of health care reforms with a general reliance on the private market. He has encouraged the health savings accounts favored by the Bush administration. He would use tax breaks to make it easier for individuals to purchase insurance and would shift Medicaid funding to states to a block grant to allow more latitude for experimentation.

In contrast to the Massachusetts model, he would not mandate coverage for individuals. And in common with his GOP rivals, he does not hold out universal coverage as a near-term priority for national health care policy.

Giuliani similarly heralds the private market as the best bet to deliver better coverage and cost control. He would provide a tax deduction for individuals purchasing health insurance along with tax credit for lower income Americans to obtain coverage. He would offer block grants to states to promote innovation in coverage solutions, including issues such as the difficulty in obtaining coverage for individuals with prior medical conditions. Giuliani, who was once treated for prostate cancer, contends that the private market is the most reliable promoter of the kind of high quality health care he received. He has denounced various Democratic proposals as recipes for "socialized medicine."

Former Tennessee senator Fred Thompson, relatively new to the race, warns against bigger government solutions to health care, but has offered few specifics as yet on what initiatives he might promote.

"Those who propose a one-size-fits-all Washington-controlled program ignore the cost, inefficiency, and inadequate care that such a system offers," he says in a statement on his Web site. "Access to affordable, portable health care can be made available for all Americans without imposing new mandates or raising taxes."

Sen. John McCain of Arizona, focused chiefly on national security, hasn't offered any detailed proposals on health care in the course of the campaign.

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