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The anemic internecine squabbles that dominated so much of the primaries have given way to a full-blown healthcare policy debate.
With the cessation of presidential primary activities last month, the parties' presumptive nominees have wasted no time in laying the groundwork for the fall campaign. The anemic internecine squabbles that dominated so much of the primaries-electability on the Democratic side, ideological purity among Republicans-have given way to full-blown policy debates, albeit ones that have thus far split mostly along traditional party lines.
Nowhere are those partisan divisions sharper than in the increasingly critical area of healthcare. Though Senators McCain and Obama each point to similar problems-the uninsured, skyrocketing costs, and the need for more preventive care and public health-their proposed solutions differ dramatically.
Like other Republicans, McCain believes the key to healthcare reform is to put more purchasing power in the hands of consumers, thereby forcing private insurers to compete on both value and price. McCain would do this by offering everyone a refundable tax credit-$2,500 for individuals, $5,000 for families. Using "transparent" data to assist them in making wise, cost-effective decisions, consumers would choose the insurance plan and product that best suited their needs. According to the McCain proposal, "those obtaining innovative insurance that costs less than the credit"-that is, high-deductible, catastrophic coverage-would be able to deposit the remainder of their credit in expanded Health Savings Accounts. For people whose pre-existing conditions or other problems make it difficult for them to buy insurance on the individual market, McCain has floated the idea of a "Guaranteed Access Plan"-essentially, a model that states would follow to create federally subsidized insurance pools for their high-risk citizens.
For people without employer-based coverage who earn too much to qualify for Medicaid and SCHIP, Obama proposes a comprehensive benefits package, modeled after the program that covers federal employees, including members of Congress. The package, delivered by private plans, would cover "all essential medical services." Obama also makes subsidies available to help low-income individuals and families buy into his program. For those purchasing strictly on the private insurance market, he promises to create a "National Health Insurance Exchange," a kind of watchdog agency to make their shopping easier and fairer.
The Obama plan gets knocked for relying too much on government-and the McCain plan for relying too much on the private market. Less ideologically driven objections have also surfaced. Some commentators, for instance, have faulted Obama's $50 to $65 billion a year cost projection as too modest, since it assumes dramatic and largely unproven cost-savings effects of measures like IT expansion. McCain's proposal, meanwhile, has come under oblique criticism in a new report from the Commonwealth Fund, which found that the trend toward cost-sharing and higher-deductible plans has resulted in a dramatic rise in the number of "underinsured."
Important questions, these. And they ought not to be lost in the fog of slogans and soundbites. In the debate over healthcare, as in other parts of the campaign, marketing matters, but ideas matter more.
The author is a senior editor of Medical Economics.