Pulling it Together: Separating the Forest from the Trees in the Health Reform Debate

The good news for those who care about health care is that the issue is rising again on the national agenda. If we have a big debate about health in the presidential campaign and if it is a factor at the polls in 2008, it will help create a mandate for the new president and Congress to make health care a priority in 2009.

But the real health care debate has been delayed by the focus in the primaries on the differences on health between candidates in each party, especially the differences between the plans put forward by the leading Democratic candidates. While the differences between the candidates’ plans can mean a lot to experts, they mean much less to voters. Senator Edwards described them as “in the weeds,” and our tracking polls  have consistently shown that differences between the candidates’ plans have not had an appreciable impact on voters in the primaries.  In general, the primaries so far have not been driven by differences on issues, but rather by the perceived differences in the leadership qualities of the candidates.  The health care debate that will come next in the general election is much more important because it’s about the truly profound gulf between Democrats and Republicans and the political right and left about the future directions our health care system should take. These are the differences that have paralyzed Washington on health reform for years and will continue to pose a formidable obstacle to compromise when a new President and Congress consider health reform legislation in 2009.

Health08.org contains a unique library of candidates’ statements on health reform, revealing not just the details of their plans, but what they emphasize most consistently about health reform and their vision for the future of the health care system.  A look at the key buzzwords and phrases used by candidates is an entertaining and quick way to reveal the key differences between the two sides.

icon_video_audio.gif Watch the key buzzwords and phrases used by the candidates.

In listening to candidates at a series of presidential candidate forums in our Barbara Jordan Conference Center and sifting through the hundreds of hours of speeches, debates, and documents by Presidential candidates about health policy we have compiled on the web, here are three critical differences between the parties that set the stage for the next health reform debate.

First, there is a basic difference on whether guaranteeing universal or nearly universal health insurance coverage should be the primary goal of health reform. Democrats consistently say it should be, though the leading candidates’ plans differ somewhat on how to get there and whose plan represents a better approach. Republicans do not have universal coverage as their overarching goal. They believe it requires too big a role for government to guarantee universal coverage and will cost too much to pay for it. Instead, they want to make coverage more available in the private marketplace and give people a tax break to help those who want it afford it. The top priority they emphasize is to create a more efficient, and in their view, more affordable private health insurance marketplace based on individual choice and competition. This, they believe will expand coverage, but guaranteeing coverage for all is not their main goal.  This difference reflects the greater priority their base gives to controlling costs over expanding coverage, as documented repeatedly in the tracking polls that Molly Brodie, who heads our polling group, and her team conduct at the Foundation.

icon_video_audio.gif Watch the candidates discuss the goals of reform.

A second big difference is in how Democrats and Republicans would organize the health insurance system. The leading Democratic candidates emphasize building on the current employment-based health insurance system and public programs. They call for greater regulation of insurers, for example requiring them to accept all applicants and limiting their administrative costs. The Republicans, by contrast, prefer a system in which more people purchase insurance themselves in the individual marketplace, with fewer requirements on insurers. While Democrats would spend more to get to universal coverage, and their plans are perceived as more expansive as a result, it is actually the Republicans who envision bigger changes because they want to see more people get their insurance in the individual marketplace rather than through the workplace where most Americans get it today.  No leading candidate on either side is proposing scrapping the current health care system, only Congressman Kucinich proposed that, but while the Democrats have the bigger plans, it is the Republicans who envision a more fundamental transformation of the health insurance system, a difference which has been lost in the discussion to date.

icon_video_audio.gif Watch the candidates discuss their differences on how to organize the health insurance system.

Third, there is also a fundamental difference in what the two sides see as the basic purpose of health insurance. Democrats favor comprehensive insurance with front-end protection, which in their view encourages more preventive care and protects people better from financial costs of an illness. Republicans generally promote plans with high deductibles on the front end and catastrophic protection on the back end, coupled with tax-preferred savings accounts people would use to pay for routine care. They believe this will encourage people to become more prudent consumers of health care and use less health care overall.  Whether high deductible health plans with savings accounts are a forward-looking reform that will introduce market incentives and lower costs as advocates claim, or represent skimpier insurance surrounded by market rhetoric as critics believe, is an important question to debate and study as these new forms of insurance enter the marketplace. My purpose here is to characterize differences, not to referee these debates. There is no question, however, that the difference between the parties on the very nature and purpose of health insurance is a fundamental one that needs to be elucidated for voters.

icon_video_audio.gif Watch the candidates discuss their view on the nature and purpose of health insurance.

When we get beyond the primaries, the two candidates will lay out their multipart health reform plans, the media will pick apart the details of the plans, and the ads and the charges and counter charges will fly. All of the rhetoric, from “shared responsibility” on the one side to “personal responsibility” on the other side, will sound appealing to many, and the public again will be confused. Of course the candidates should be accountable for the substance of the plans they propose, but details will matter much more when there is a legislative debate in 2009. Moreover, with presidents having learned the hard way about the limits of a “my way or the highway” approach to health reform in 1993, the debate this time may be driven as much by ideas hatched in the Congress as by the President and the Executive Branch.

If we are to have a meaningful debate about health in the campaign, the bigger challenge will be to look beyond the details of plans proposed in a political campaign and debate the basic, very fundamental differences in priorities and direction for our health system being offered by the two sides, which are evident from the video clips from the campaign trail. This is especially a challenge for the news media, which often sees its role as exposing the juiciest details of the candidates’ plans rather than explaining more fundamental choices.  By focusing on the forest as well as the trees, we could have a health care debate that will engage the American people rather than confuse them, and set the stage for the even more difficult task of bridging health care’s ideological divide in the Congress in 2009.

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The independent source for health policy research, polling, and news, KFF is a nonprofit organization based in San Francisco, California.