Presidential Politics and the Resurgence of Health Care Reform (New Eng Jour Med)

[pinto]

Volume 357:2101-2104 November 22, 2007 Number 21

Presidential Politics and the Resurgence of Health Care Reform
Jonathan Oberlander, Ph.D.

Comprehensive health care reform disappeared from the national agenda after the Clinton administration failed to enact universal coverage in 1993 and 1994. Instead, Congress adopted incremental measures that enjoyed bipartisan support, including the State Children's Health Insurance Program (SCHIP) and the Health Insurance Portability and Accountability Act (HIPAA). The retreat from comprehensive reform reflected, in part, the calculus that ambitious plans were too controversial and too hazardous to their sponsors' political health to attempt. But that political calculus is changing. Health care ranks as the top domestic issue in opinion polls, and talk of major reform is back in vogue as the 2008 election approaches.

Democratic and Republican voters have contrasting views on health care reform (see graph), so not surprisingly, the issue is playing out very differently in the parties' presidential primaries. The leading Democratic candidates have all released comprehensive, detailed plans. Former Senator John Edwards (NC) was first out of the gate with a plan, and Senators Barack Obama (IL) and Hillary Clinton (NY) subsequently unveiled their own proposals. The plans are remarkably similar. All three aim to cover all or nearly all uninsured Americans, to build on the current mixed system of private and public insurance, and to avoid making any changes that would unsettle people who are currently insured.

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The Democratic health plans share three other key features. First, they avoid any explicit budgeting of health care spending or centralized cost controls — provisions that the health care industry would fiercely resist. Instead, they offer a politically friendlier assortment of cost-saving measures, including electronic medical records and a focus on prevention and disease management. These measures may be good health policy, but their capacity to generate large savings is uncertain, and they are unlikely to restrain health care spending for long.

Second, the Democratic plans are financed largely by rolling back tax cuts adopted by the Bush administration for families making more than $200,000 (Edwards) or $250,000 (Clinton and Obama) annually. That makes health care reform explicitly redistributive and turns the election into a referendum on tax policy. Democratic presidential candidates are, in essence, betting that the public would rather spend federal money on covering the uninsured (and making coverage for the already-insured more secure and affordable) than on extending tax cuts for the wealthy. The Democratic plans thus depend crucially on the politics of tax reform.

<snip>

The 2008 presidential election will not resolve the debate over health care reform, but the results will go a long way toward determining the future of U.S. health policy. It would be a mistake, however, to read the candidates' plans too literally. A plan offered during the primaries usually looks different in key respects from the plan that a newly elected president takes to Congress, to say nothing of any legislation that Congress actually passes. Still, it is clear that there is a wide partisan gap on health care reform that reflects ideological divisions over the roles that government and market forces should play in the health care system. And the further U.S. health policy moves from incrementalism, the more that partisan divide is likely to be exposed.

Source Information

Dr. Oberlander is an associate professor of social medicine and of health policy and administration at the University of North Carolina, Chapel Hill.

An interview with Dr. Oberlander can be heard at www.nejm.org.

The New England Journal of Medicine is owned, published, and copyrighted © 2007 Massachusetts Medical Society. All rights reserved.

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http://content.nejm.org/cgi/content/full/357/21/2101?query=TOC

[WeCanWorkItOut]

1. "mandates vulnerable to charges of unfairness" --It's an important problem

Before (or inside?) the second "snip," Oberlander also observes,
". . . individual mandates are vulnerable to charges of unfairness,
since health insurance remains unaffordable for many Americans;
the political risk is that health care reform could appear punitive."