USA elections: Health Care Debate, Part 2

Health Care Debate, Part 2
THE skirmishing between the Democratic presidential candidates over the mechanics of universal health coverage will soon give way to a quite different general-election debate — about whether universal coverage should even be a national priority.

In the primaries, Senators Hillary Rodham Clinton and Barack Obama have magnified their differences over making health insurance mandatory because it provides a rare chance to differentiate themselves on an issue that matters deeply to Democrats. But they are fighting over the narrowest of bands in a broad policy spectrum, and the focus on universal coverage — rather than on cutting costs — may have far less resonance come Nov. 4.

Senator John McCain, the presumptive Republican nominee, agrees with the Democrats that the health system needs major repair. But his solution would stress cost-containment over assuring coverage for all. Its most controversial elements would fundamentally alter the employer-based insurance system through which 71 percent of insured Americans now get their health coverage.

Like President Bush, Mr. McCain wants to use tax policy to create an insurance marketplace that he says would be more competitive. He would end the longstanding tax exemption on health benefits paid by employers, to eliminate what he says is a bias against those who buy insurance individually.

Instead, anyone who buys health insurance would receive refundable tax credits of $2,500 per individual and $5,000 per family. To promote competition, Mr. McCain would allow policies to be sold across state lines and by organizations like churches and trade groups.
The most difficult to insure — the elderly and those with health problems — would be eligible for larger credits, though Mr. McCain has not specified the amounts. By contrast, the Democratic plans would simply prohibit insurers from denying coverage because of health status.

The McCain campaign has no estimate of how many of America’s 47 million uninsured would likely gain coverage under its plan. But Mr. McCain’s emphasis is elsewhere. “The biggest problem with the American health care system,” he said in an October speech, “is that it costs too much.”

The Democratic candidates have not ignored the cost side of the health care equation. Like Mr. McCain, both have articulated plans to reduce the rampant growth of health spending through improvements in prevention, electronic record keeping and chronic-disease management. When Mrs. Clinton introduced her health plan last year in a series of three speeches, she pointedly devoted the first to lowering costs.

But anyone paying attention to the Democratic campaign over the last two months could be excused for thinking that universal coverage is the candidates’ fundamental concern. Last Saturday, Mrs. Clinton drew attention by scolding Mr. Obama (“Shame on you, Barack Obama!”) for what she said was a distortion of her position in a mailing. Three days later, the candidates spent the first 16 minutes of their debate in Cleveland disagreeing over whether everyone should be required to have insurance (Mrs. Clinton says yes; Mr. Obama says only children should be).

Jonathan B. Oberlander, an authority on health politics at the University of North Carolina at Chapel Hill, predicted that in the general election the Democrats might regret how much time they spent discussing government mandates, and the tax increases they have proposed to support broad expansions of coverage. “It’s just not how you want to sell health reform,” he said.

Polling suggests that at least 9 of every 10 voters in November will be insured. Many will not see universal coverage as a matter of self-interest. The complex economic argument that the uninsured impose hidden costs on everyone else may be difficult to convey in sound bites.
And the electorate may be less receptive than participants in the Democratic primaries and caucuses. A December poll by the Kaiser Family Foundation found that 42 percent of Democrats said their top health policy concern was expanding coverage for the uninsured, while 35 percent said it was reducing costs. The priorities flipped when Republicans and independents were added to the mix, with 41 percent of all polled saying they cared most about reducing costs and 31 percent citing coverage for the uninsured

Michael F. Cannon, the director of health policy studies at the Cato Institute, argues there is no way to know whether universal coverage — estimated by both Democratic campaigns to cost at least $110 billion — would be the most cost-effective means of improving the country’s health.

Mr. Cannon, a libertarian who used his blog to found the Anti-Universal Coverage Club, acknowledges that a substantial body of research has shown that health coverage can improve health outcomes. Studies by the American Cancer Society, for instance, have found that the uninsured are significantly more likely than those with private insurance to be diagnosed with cancer in late stages rather than early stages.

But he cites a highly-regarded 2001 survey by two University of Chicago researchers, Helen Levy and David Meltzer, who said, “there is no evidence at this time that would allow us to say whether money aimed at improving health would be better spent on health insurance or on inner-city clinics, community-based screening programs for hypertension or advertising campaigns to encourage good nutrition, to name just a few possibilities.”
Mr. Cannon, along with a number of conservative theorists, contend that spending on unneeded procedures, medical errors and hospital infections is a more dire problem than the cost of caring for the uninsured. They say that waste accounts for a much larger share of the country’s $2.1 trillion health care bill, and that at least twice as many Americans are estimated to die each year from medical errors as from lack of access to care.

The toxic politics of appearing to support any rationing of care has kept candidates in both parties from seriously confronting the overuse and misuse of health care, they say. Without change, health spending is projected to double by 2017, eating up 20 percent of gross domestic product.

“The pernicious aspect of this cry for universal coverage is that it is too easy for politicians,” said Joseph R. Antos, a health policy expert at the American Enterprise Institute. “The hard work is getting at the underlying inefficiencies in the health system, the perverse incentives that have everybody operating in the dark.”

Supporters of universal coverage counter that its benefits would go well beyond its impact on health spending. Mrs. Clinton, for instance, speaks passionately about making health care in America more equitable and removing the ability of insurance companies to “determine who lives and who dies, who gets health care and who does not.”
Len M. Nichols, director of health policy for the New America Foundation, and a supporter of a health insurance mandate, said the ledger also must account for the economic and social costs of the deaths, disabilities and bankruptcies attributable to lack of insurance. “The right question is: would coverage expansion add enough social and economic value to merit the investment?” he said. “The literature suggests a resounding yes.”

Other health experts say it would be regrettable if the general election devolves into a debate that pits coverage against cost. In fact, they say, the government must fight on all fronts simultaneously to have any chance at meaningful change. “If reforming U.S. health care results only in expanded access to care, costs will increase faster but with limited health benefits,” Thomas R. Frieden, New York City’s health commissioner, wrote last week in The Journal of the American Medical Association. “If only cost controls are instituted, even more individuals will be denied access to needed care. Health care must be restructured to make maximizing health the organizing principle.”
NYTimes