Providing greater access to health care and deciding how to pay for it emerged as early issues in the presidential campaign, with Democratic candidate Sen. Barack Obama calling for creation of a national health plan and Republican candidate Sen. John McCain arguing for reform of health insurance.
In this article, several physicians share their views of the candidates’ proposals, as well as other issues related to Obama’s and McCain’s positions on health care.
Under Obama’s health care proposal, those people who do not have employer-provided health care and who do not qualify for other existing federal programs could choose to purchase a government-sponsored plan or make a selection from several private insurers. No one would be denied the chance to apply for insurance based on preexisting medical conditions under Obama’s plan. Those without employer-provided coverage would be eligible for a subsidy, based on income, so that they could buy into the national public plan or purchase a private plan.
“If you already have health insurance, the only thing that is going to change for you under this plan is the amount of money you will spend on premiums,” Obama said in a video posted on his website.
Obama has indicated that revenue to cover the ‘National Health Insurance Exchange’ would come partially from the expiration of federal income tax cuts for Americans earning more than $250,000 per year. He also contends that savings throughout the health care system would provide additional funding for the plan.
Also under his plan, employers that do not offer or make a significant contribution to employees’ health coverage would be required to contribute a percentage of paid wages toward the costs of the national health plan. Small businesses would be exempt from this requirement and would receive a refundable tax credit of up to 50% on premiums paid by those businesses for their employees, a credit that “will provide a strong incentive to small businesses to offer high quality health care to their workers,” according to the campaign.
Health insurance quality
McCain’s proposal would “use competition to improve the quality of health insurance with greater variety to match people’s needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.”
The McCain website states: “While still having the option of employer-based coverage, every family will receive a direct refundable tax credit — effectively cash — of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best, and the money would be sent directly to the insurance provider. Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts.” McCain’s proposal, like Obama’s, would allow individuals to retain their health insurance when they move or change jobs.
Stating his desire to deregulate and encourage competition to improve health insurance quality, McCain has proposed taxing health insurance supplied by employers. His campaign has estimated that this tax would generate approximately $3.6 trillion over the next 10 years; an amount it says will cover the tax credits to individuals and families.
According to McCain’s website, one approach to providing greater access to care would be establishment of a nonprofit corporation to contract with insurers to cover patients who have been denied insurance and which could join with other state plans to enlarge pools and lower the costs of overhead.
Physicians comment on proposals
Hematologist Harry Jacob, MD, of the University of Minnesota, said that neither candidate’s proposal goes “far enough into detail. In my opinion, McCain’s proposals, particularly, are seriously wanting. Obama’s are better but they don’t go far enough either because, I think, of political considerations.”
McCain’s plan would result in more people being uninsured, Jacob said. “The great failure of the plan is that it continues to depend exclusively on private health insurance. The subsidies are so minimal it’s ridiculous.” For patients with cancer, finding and keeping health insurance with a preexisting condition would be a problem under McCain’s plan, Jacob said.
Endocrinologist Richard Dolinar, MD, of the Heartland Institute in Chicago, said that even if “you voted for one candidate, you should be equally happy if the other gets in because both candidates are similar when it comes to health care. Both are in favor of greater government intervention in various ways.”
Dolinar said that even though he is in favor of McCain’s proposal to allow greater portability of health insurance coverage across state lines, he worries about the candidate’s stance on pay-for-performance.
“If you set a doctor up on a pay-for-performance basis, you are going to fundamentally change the doctor-patient relationship because, ultimately, you will look at how you are treating the patient as a ‘will this patient help or hurt my statistics?’ type of situation,” he said.
According to cardiologist Douglas Weaver, MD, president of the American College of Cardiology, McCain should be praised for tackling cost issues, and Obama “should be applauded for attacking disparity issues. We support the idea of trying to link payment to the type of care that is delivered.”
He said that he hopes that a new president will initiate a pilot project where appropriateness criteria and guidelines are embedded in electronic tools so that the industry can get real-time data on the type of health care that works, as well as an assessment of its cost.
Douglas W. Jackson, MD, an orthopedic surgeon in Long Beach, Calif., said that allowing health care coverage to cross state lines is a good move toward more accessibility and affordability of care.
“The costs for similar plans can vary by two to three times as much in different states. This possibly may allow 10 million or more individuals the ability to afford and/or purchase health insurance,” he said.
A key issue of concern for many physicians is accessibility to health care by uninsured and underinsured patients. The State Children’s Health Insurance Program, SCHIP, was funded jointly by the federal government and the states and was considered a compromise plan when created in 1997, after Congress turned down the Clinton administration’s proposed restructuring of the health care industry.
The original idea behind SCHIP was to provide health insurance to low-income children whose families earned too much to qualify for Medicaid.
The Obama proposal would expand that concept by offering subsidies to people who do not qualify for SCHIP or Medicaid but need funding to get insurance. Obama’s proposal would mandate coverage for all children and would expand eligibility requirements for the Medicaid and SCHIP programs. Under his proposal, young people could continue to be covered under their parents’ health plans through age 25.
McCain’s proposal would promote the use of community health centers and walk-in clinics located in retail stores to supplement existing children’s health insurance programs. “If walk-in clinics in retail outlets are the most convenient, cost-effective way for families to safely meet simple needs, then no policies of government should stand in their way,” McCain said in a speech at the Lee Moffitt Cancer Center & Research Institute in Tampa, Fla.
Although he favored President Bush’s proposal to increase SCHIP spending by $20 billion over five years, McCain has voted against proposed expansions of the program, arguing these proposals do not go far enough to emphasize poor children first.
Providing coverage for the underinsured and uninsured should be further explored in both of these plans, according to Renee Jenkins, MD, president of the American Academy of Pediatrics.
“The Academy wants more access to care for children … and we want the physicians that care for them to be adequately reimbursed,” she said.
“We thought we were going to get there with the SCHIP plan, but then [increased funding] got vetoed. We are hoping we get an administration that looks at the evidence about how much we’ve been able to gain under this program, and expand it. Obama starts in that direction, but the devil is in the details.”
The Academy’s MediKids plan, introduced in May 2007 by California Democrat Rep. Pete Stark, would provide the best safety net for children, Jenkins said. Introduced in the last five congressional sessions, MediKids, if enacted, would provide access to quality health care for every child by providing automatic coverage and increasing payment rates to Medicare levels, she said.
Dollars for research
Another issue of concern cited by many physicians contacted for this article is the candidates’ position on funding for and support of scientific research.
“In recent years, we have become alarmed by the increasing intrusion of politics and other agenda into the realm of science and medicine,” Donald Poretz, MD, president of the Infectious Diseases Society of America (IDSA), and Arlene Bardeguez, MD, chair of the HIV Medicine Association, wrote in a recent letter to the candidates.
They said that several controversial issues — such as the alleged link between autism and vaccines and the appropriateness of sex education programs — deserve more research dollars. Poretz said that whichever candidate is elected should scrutinize the issues and look to science to guide policy.
Both IDSA and HIV Medicine Association are hoping for a change in the government’s stance toward sex education programs. “It would be foolhardy to rely on abstinence prevention programs alone,” according to Poretz and Bardeguez, who noted that federal funding for programs teaching abstinence-only methods for preventing sexually transmitted diseases has increased under the current administration.
Jacob said he is hoping there is a change in policy and funding for scientific research, and he pointed to his disagreement with the current administration’s stance on embryonic stem cell research.
“One thing where I agree with the Republicans is getting the government out of the scientific realm. Things like stem cell research are quite critical in improving the chance of survival for patients with malignancies,” he said.
Both candidates should emphasize and support funding for early intervention programs, according to several physicians who were interviewed for this article.
“Getting people engaged in the system early and giving them a medical home is very important,” Jenkins said. “As with most things in medicine, the earlier you catch it, the less you have to do.
“Cervical cancer, colon cancer, mammograms: When you do all those things early on, ultimately it ends up being less costly,” she said.
In their letter to the candidates, Poretz and Bardeguez said the goal of physicians is “to help all our patients become well. To do so, we must be able to rely upon prevention, diagnosis, and treatment strategies that are supported by the medical and scientific evidence.
“As an influential member of the U.S. Senate — and possibly as the next President of the United States of America — you are in a unique position to foster public health strategies that are well grounded in science. Nothing less than the health of the nation is at stake,” they said.
Colleen Zacharyczuk is the executive editor of O&P Business News’ sister publications of Infectious Disease News and Infectious Diseases in Children; Lee Beadling is managing editor of O&P Business News’ sister publication, Orthopedics Today; and Matt Hasson is a staff writer for O&P Business News’ sister publication Ocular Surgery News.