The impressively detailed and surprisingly thoughtful presidential debates provided a clearer understanding of a fundamental difference between the candidates on health policy, though average voters may be excused for being confused by the abundance of nomenclature.
I counted 42 references to "healthcare" in the third debate alone. Who would have thought that phrases such as tort reform, catastrophic care, electronic medical records, Canadian drug reimportation, health savings accounts and the VA healthcare system would have received such thorough discussion?
Although there was plenty of demagogy-with President Bush claiming John Kerry seeks a government takeover of the healthcare system and Kerry claiming that Bush's Medicare plan is the main culprit behind rising healthcare costs-this may have been the most substantive dialogue on health policy of any presidential campaign.
A theme running through all of this verbiage was the real difference in the two men's approaches. Kerry believes government must come to the rescue of the current group health insurance system while Bush favors a market system in which individuals buy their own coverage and cut their own deals with providers.
In this sense, Kerry is actually the traditionalist, albeit one who seeks to greatly expand the federal role in keeping the faltering employer-based system alive. His philosophy is that healthcare is a social necessity and that government must act where the private sector leaves off. His plan is to make the government a sort of guarantor of group health solvency, while offering those who lack such coverage access to federal government health plans, either by paying into them or qualifying for aid.
Bush is in the novel position of being the radical, seeking not to prop up the current employer-based system but to gradually replace it with a patchwork of tax credits, health savings accounts, privatized Medicare plans and association health plans. He views healthcare as another consumer product and believes that only informed consumers using their own dollars will make the right choices in the private marketplace, helped along with a dash of information from voluntary quality initiatives.
None of his offerings have been subject to empirical testing and each has major drawbacks, but it is Bush's vision that is closer to being realized. Health savings accounts and Medicare managed care were part of the Medicare Modernization Act. Association health plans, through which business groups offer skeletal coverage without state regulation, are only a few Senate votes short of passage.
Should he win election, Kerry's grander vision is unlikely to win support from a Republican-dominated Congress, unless he pursues the sensible course of a piecemeal, pay-as-you-go program.
Sadly, neither candidate has made cost control much of a priority. Sorry, Mr. President, but tort reform won't do it, and a national health IT system is a pipe dream unless you invest federal dollars in getting it done. Kerry does forecast some cost control through changing the MMA to allow for negotiated drug purchases but pays only lip service to true reform of the care delivery system.
Nevertheless, this has become a most interesting election from a healthcare perspective. Voters, if they can sort out what's really being offered here, have a real choice on this issue. They can pick between a candidate who wants to spend big to cover more Americans through the older, more established coverage model, or continue down a path they may not have realized they are on, toward a consumer-driven health system.
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