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Health Care Reform and the Presidential Candidates
The editors asked Senator John McCain, the Republican presidential nominee, and Senator Barack Obama, the Democratic presidential nominee, to describe their plans for reforming the U.S. health care system. Their statements follow. In order to explore their positions in greater depth, the Journal and the Harvard School of Public Health cosponsored a Perspective Roundtable on September 12, 2008, entitled "Health Care in the Next Administration" and featuring senior health policy advisors David Cutler for Senator Obama and Gail Wilensky for Senator McCain. A video of the symposium can be seen at www.nejm.org.
Americans deserve leadership for real health care reform that provides access to high-quality medical care and ends spiraling costs. But the road to reform does not lead through Washington and a hugely expensive, bureaucratic, government-controlled system. We have all tangled with the existing bureaucracy enough to know that such an approach would diminish, not improve, quality. Our challenge is to protect and improve the care that doctors, nurses, and hospitals deliver, while increasing the availability and affordability of health insurance for Americans. I believe we can do this in a simple but powerful way: restoring doctors and patients to the center of health care decisions.
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Underlying our health care system's many troubles are the fundamental problems of cost and access. Rising costs hurt those who have insurance by making it more expensive to keep. They hurt those who don't have insurance by making it even harder to obtain. Rising health care costs hurt employers and the self-employed alike. And in the end, they threaten to do serious and lasting harm to the entire American economy.
I support a comprehensive and inclusive approach to lowering costs and reforming our health care system with a focus on four pillars:
Access and choice: Every American should have access to quality and affordable coverage of their choice, including keeping their current coverage. American families — not government bureaucrats or insurance companies — should choose the coverage that best meets their unique needs.
Quality: Strengthening health care quality requires promoting research and development of new treatment models, promoting wellness, investing in technology, and empowering Americans with better information on quality.
Affordability: We need genuine competition in the health sector to ensure that drug companies, insurance companies, hospitals, and every other aspect of the health care system are responding to the needs of American families. By rewarding quality, promoting prevention, and delivering health care more effectively and efficiently, we can ensure that all Americans can afford the health care coverage of their choice.
Portability and security: We must allow Americans to keep their health insurance as they move from job to job or job to home, and we must protect Americans' economic security from unforeseen health events by expanding coverage and savings options.
Doctors and patients understand that bureaucracies — both within government and within insurance companies — often impede the effective delivery of high-quality care. I believe that we can use government programs like Medicare as a lever of change that improves quality and lowers costs, rather than allowing it to be an obstacle to effective patient care.
I understand that when Medicare squeezes providers to lower the cost of care, the result is distortion of the care that patients receive and increased prices for everyone else. In short, you get what you pay for. We need to work together to reform Medicare, moving away from a system in which government bureaucrats choose how much to pay doctors for fragmented services and toward a system that rewards coordinated care and higher-quality care for seniors.
One of the challenges we must face in reforming our health care system is that of finding ways to keep the American people healthier. Chronic conditions — such as cancer, heart disease, high blood pressure, diabetes, and asthma — account for three quarters of the nation's annual health care bill. Often, the suffering caused by these conditions could be averted by early testing and screening, as in the case of colon and breast cancers. Rates of diabetes and heart disease are also increasing today, with the increase in obesity in the United States, even among children and teenagers.
We need to create a next generation of efforts to prevent chronic disease, early intervention programs, new treatment models, and public health infrastructure. We need to use technology to share information on "best practices" in health care so that every physician is up to date. We need to adopt new treatment programs and financial incentives to promote healthy habits among Americans with the most common conditions, such as diabetes and obesity, in order to improve their quality of life and reduce the cost of their treatment.
While we take steps to lower health care costs, we must also improve access to health insurance. An important part of my plan is to replace the current tax exclusion of the value of health insurance from employees' taxable compensation with a new refundable tax credit of $2,500 for individuals and $5,000 for families. Families can use the tax credit to continue their employment-based insurance or to find a plan that better meets their needs.
Families who have job-based insurance today will see little to no change and will continue to keep their current coverage. In fact, millions of American families with employer-sponsored coverage will be better off under this fair and equitable system. However, for the first time the credit will provide help to people who are shut out of the job-based insurance system; they will be able to choose an insurer or other health care arrangement, and the credit will be sent straight to the plan they pick in order to help pay their premiums.
An essential benefit of this reform is that it will help to change the whole dynamic of the current health care system by putting individuals and families back in charge and forcing insurance companies to respond with better service at lower cost. It will also allow Americans to take their health care with them when they change jobs and enable families to stay with the doctors and providers of their choice. When Americans speak of "my doctor," it will mean something again, because they won't have to change from one doctor or one network to the next every time they change employers.
No American should be denied access to affordable coverage simply because of a preexisting condition such as cancer. I will work with states to create guaranteed-access plans that will ensure high-quality coverage, with reasonable premium limits, for these Americans and additional help for low-income individuals.
Our tort system is an invitation to endless, frivolous lawsuits by trial lawyers who exploit patients and physicians alike. I understand that the fear of lawsuits not only forces doctors to perform unnecessary tests but also often poisons the relationship between patients and doctors. That is why I have been a consistent advocate of medical-liability-reform legislation, and I believe it must be a central aspect of any health care reform effort.
Health care reform is too important an issue for one person or one party to tackle alone, and I have a record of working across party lines to tackle big challenges and change the way Washington works. By starting with putting doctors and patients back at the center of health care decisions, we can reform the U.S. system in a way that protects the quality of care while making it affordable and accessible to all.
I do not believe that reforming our health care system should mean issuing burdensome mandates that push American families away from private coverage and creating new government bureaucracies that will translate into higher taxes, reduced provider payments, and long waiting lines. The key to real reform is to strengthen the doctor–patient relationship and provide American families with more choices for high-quality and affordable care.
Source Information
This article (10.1056/NEJMp0807607) was published at www.nejm.org on September 24, 2008.
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