Presidential candidates Sens. John McCain (R, Ariz.) and Barack Obama (D, Ill.) both have started to write prescriptions for health system reform with an eye toward tackling many of the nation's most serious conditions. But because these orders are incomplete, the effects they will have on doctors and their patients are difficult to predict.
The two leading candidates are "proposing some broad outlines of what they would intend to do and waiting to fill the details in later," said Sara Collins, PhD, assistant vice president for the Commonwealth Fund's Program on the Future of Health Insurance.
McCain and Obama both support better pay for doctors who meet quality standards and who coordinate care. They want more transparency in the system and widespread adoption of health information technology, and would consider allowing importation of prescription drugs to reduce prices.
But they part ways on their visions to reform the market for health insurance and to expand coverage. McCain would end the employee tax exclusion for health insurance spending, instead offering refundable tax credits to help people buy health insurance. He also would work with states to create guaranteed access plans for Americans with expensive chronic conditions and those denied health insurance coverage. Health plans could sell policies across state lines under his plan to increase insurance portability and competition.
Obama would cover all uninsured kids and more uninsured adults by expanding eligibility for Medicaid and the State Children's Health Insurance Program. He also would create a national health insurance exchange that would offer benefits similar to those in federal employee health plans, with guaranteed eligibility and subsidies for lower-income people. The exchange would take bids from private insurers to offer competing plans.
Covering more patients
The McCain and Obama plans both seek to expand health coverage to the uninsured -- potentially putting millions more paying patients in doctors' offices -- but would take different paths to get there.
McCain's guaranteed access plans would limit premiums and provide subsidies for lower-income people. Plans would likely be restricted to individual states at first, and talks with governors and legislatures might allow them to be expanded into regions, said Tom Miller, an unpaid health care adviser to the McCain campaign and a resident fellow at the American Enterprise Institute. "But that's a little bit up in the air."
The McCain plan to allow insurers to sell their plans nationwide instead of only on a state-by-state basis doesn't specify how these interstate plans would be regulated. Miller said an agreement might be reached to allow the insurer's home state to take the lead on handling consumer complaints, with the enrollee's home state as a backup. In any case, consumers will be the ultimate judges of such plans, he said. "If [health plans] don't carry out their promises they're not going to succeed."
One concern about the McCain plan is that it won't significantly reduce the number of uninsured people, according to an analysis released July 23 by the Tax Policy Center, a collaboration between the Urban Institute and Brookings Institution. The report assumes the number of uninsured Americans will increase to 59.2 million by 2013 and 66.8 million by 2018, absent any policy changes.
That analysis paints this picture: McCain's plan would decrease the uninsured number by 4.6 million by 2013. By 2018, McCain's plan would cover only 2 million people who would otherwise be uninsured because increases in health spending would outpace the value of the plan's tax credits. In contrast, the Obama plan would shrink the uninsured population by 29.6 million by 2013 and 33.9 million by 2018.
Miller disagreed with the estimate on the McCain plan, saying that the analysis overestimates the number of employers that would drop coverage. "That's not what's going to happen in the real world."
The Tax Policy Center analysts acknowledged that their estimate is "very preliminary" because it includes a number of assumptions about the funding and structure of the McCain plan that the campaign has not detailed.
Obama's national health insurance exchange would be modeled partly on Massachusetts' Commonwealth Connector Authority. The connector, in an effort to offer affordable coverage to the uninsured, defines minimum levels of benefits and sets affordability standards for participating private plans. In return, the connector subsidizes coverage based on income. Obama's exchange would take that model nationwide by creating one public, national plan with benefits similar to those offered to federal employees, said unpaid Obama campaign adviser David Cutler, PhD, a professor of economics at Harvard University. The public plan would then serve as a benchmark for private plans participating in the exchange.
Obama would fund the expansion in part by requiring employers who don't make a high enough contribution to their employees' health care to pay into the national plan. But the higher the contribution, the more likely it will increase employment costs, which could lower wages without improving coverage, according to the Tax Policy Center's analysis.
Small businesses would be exempt from the payroll contribution and would receive tax credits of up to 50% of what they spend on employees' premiums. That could make coverage more affordable for employees in small physician practices, said Robert Doherty, the American College of Physicians' senior vice president for governmental affairs and public policy.
If Obama or McCain succeed in covering millions of the uninsured, they would also need to ensure that enough physicians will be available to see them, said E. Stephen Edwards, MD, a retired pediatrician and past president of the American Academy of Pediatrics. "We're going to need a lot more physician power than we currently have."
Neither candidate's plan addresses the physician work force issue.
Dodging the Medicare pay question
McCain and Obama both call for turning Medicare and other public programs into models for rewarding physicians and hospitals for higher quality care. But neither candidate offers a strategy for reforming the sustainable growth rate formula that for several years has called for annual cuts to Medicare physician pay.
Although Congress in July reversed the latest Medicare pay cut, the measure did not adjust the sustainable growth rate formula, which means doctors will be facing a projected 21% Medicare pay cut on Jan. 1, 2010. Obama voted to override the cut. McCain did not vote, but he issued a statement criticizing the bill for slashing private Medicare plan payments to help boost physician pay.
McCain would stop Medicare and Medicaid from paying for medical errors deemed preventable, and Obama suggests such errors should be reported publicly. But advisers to both campaigns indicated that reducing physician pay for failing to meet quality goals in Medicare and other public programs was a less attractive option.
A new pay system would be much easier to implement if it focuses more on rewards than penalties, McCain adviser Miller said. Likewise, Obama adviser Cutler said most policy analysts call for rewarding doctors who perform well, instead of penalizing those who don't.
Dr. Edwards said defining quality care in any type of pay-for-performance initiative would be difficult. The process must be more meaningful than simply making sure paperwork is filled out correctly, he said.
Both candidates have been largely silent on Medicaid and SCHIP physician pay, though both want at least to cover all children eligible for the programs. Dr. Edwards said he appreciates that commitment but that it's not enough. "That doesn't mean doctors are going to be compensated fairly for the work that they do."
Two-thirds of SCHIP plans pay the same as state Medicaid programs, which generally pay physicians less than Medicare does, he said.
Boosting health information technology
Both the McCain and Obama plans call for expanding use of standardized electronic records systems and health IT to reduce medical errors, improve efficiency and improve transparency.
"You can't find a politician who doesn't support the concept of health IT," said Joseph Antos, PhD, a health care scholar at the American Enterprise Institute.
Obama would spend $50 billion over five years to speed adoption of electronic records systems. The government would assist physicians and hospitals in paying for and implementing the systems, Cutler said.
McCain also calls for wider use of health IT, but he doesn't offer a dollar figure to spend on it. The candidate believes that widespread agreement on technology standards are needed before determining how much money is necessary, Miller said. McCain also proposes allowing physicians and other health professionals to use technology to practice across state lines. Miller said that might include services as simple as remote patient monitoring or as complex as patient-doctor consultations.
Both candidates call for more public reporting of medical outcomes, quality measures and costs, but Obama would go further by requiring physicians and hospitals to report medical errors, hospital-acquired infections and disparities in care.
McCain and Obama also don't share the same vision for medical liability reform. McCain proposes limiting liability for physicians who follow evidence-based standards. Obama supports alternative methods of resolving medical lawsuits, such as the model employed at the University of Michigan Health System. That program involves investigating, admitting to, apologizing for and compensating patients for undisputable medical errors, even if a lawsuit hasn't been filed.
Obama campaign adviser Kavita Patel, MD, said the Michigan model is promising. "That is exactly the kind of cultural shift that Senator Obama ... will bring to health care," she said.
Keeping an open mind
Policy experts didn't expect McCain and Obama to fill in all the details of their health system reform prescriptions before the election. Whoever becomes president will still need to seek congressional approval to advance his ideas, with McCain likely having a tough time selling his tax credit proposal to Democrats on Capitol Hill, said the American Enterprise Institute's Antos.
Obama's plan lacks detail because he doesn't want his plan to be too prescriptive, Cutler said. "The senator believes very strongly that we need to work with people, not impose upon people."
For Obama, that tactic means not offering a take-it-or-leave-it proposition, much as the way Sen. Hillary Rodham Clinton (D, N.Y.), then first lady, was perceived as presenting health system reform in the early 1990s, Cutler said. "We're very sensitive about not wanting to give that impression."
Antos offered an alternative explanation. "They're smart. These are politicians running for office, so the last thing they want to do is to tell you want they really want to do."