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Health policy: Candidates say it's a priority, but have different ideas about reform

Health care has long been a prominent issue at the federal level, but recent years have brought little progress toward improving a system that is widely perceived to be broken.

Both John McCain and Barack Obama say they want to substantially reform the health care system. However, no plan under consideration aims to "fix" the system once and for all, says Nicole Quon, an Indiana University specialist in health policy and politics.

"Our health system is not static. It's constantly changing," said Quon, an assistant professor in the School of Public and Environmental Affairs. "We like incremental reform in the United States."Quon said health care is "usually an important issue in elections," and this year's presidential campaign is no exception, with most of the political discussion focusing on issues of access and cost.

Healthcare America

First, each candidate recognizes a need to extend coverage to at least some of the 47 million uninsured Americans, many of whom go without needed medical procedures or medicines. Second, many people who do have coverage are worried about what they're spending on health care; health-care costs are a concern both for individuals and employers.

Quon said the current economic downturn intensifies the concern, but it's hard to say if it will make reform more or less likely. On the one hand, the more people struggle to pay their medical bills, the more pressure there is for the government to act. On the other, substantive reforms are likely to cost money that the government doesn't have.

"Many people are unsatisfied with our current system, but there is little agreement on which alternatives would be best," Quon said.

Of the two candidates, Obama has a more detailed platform -- partially as a result of his Democratic primary contest with Hillary Clinton, who has been involved in the national health policy debate since the early 1990s. Obama has recognized health care as a "right" and seeks to mandate coverage for children, though not for adults. He wants a more equitable system with an expanded role for government, aimed at significantly reducing the number of uninsured.

But Obama has not sought to mandate universal coverage or to propose anything like a Canadian-style, single-payer health care system. "Political candidates usually do not propose dramatic reforms that could alienate voters," Quon said.

McCain seeks to use the tax code to address inequities in the system. He would provide a refundable tax credit -- $2,500 for individuals or $5,000 for families -- that could be used to buy health care plans. At the same time, he would eliminate the tax exemption for employer-provided health care costs.

McCain argues that his system will improve efficiency by letting the market respond to the demand for coverage. Under his approach, the government would give the same tax break to people who purchase their own health-care plans as to those who are covered through their jobs.

"This proposal reflects a different way of thinking about fairness," Quon said.

Quon said there are problems with both plans. Neither would help all 47 million uninsured. While both candidates claim to fund their programs, they are unlikely to be budget neutral. Finally, neither seems likely to discourage businesses from discontinuing health insurance for their employees, as many have recently done.

An analysis by several economists, including Anne Royalty at Indiana University-Purdue University Indianapolis, concluded that the number of uninsured who could buy health care under McCain's plan would be offset by those whose coverage is dropped by their employers.

Quon pointed out that the Obama and McCain plans do share some common elements. Both call for easing restrictions on drug re-importation, cracking down on questionable medical lawsuits and improving programs for managing chronic diseases.

While health care reform may be a priority for both sides, enacting changes in 2009 is likely to depend on the condition of the economy, the make-up and attitude of Congress and other circumstances beyond the next president's control.

"Who knows what the political and economic situation will be in January?" Quon said. "It is hard to predict if either of them would be able to enact the policies that they are proposing."