Fully 56 percent of
However, the candidates differ signifi-
Introduction
cantly in how to achieve their goals. Senator
Americans believe
Obama generally turns to the government
that our health
for answers. His plan relies heavily on gov-
Our health care system is broken:
care system has
ernment mandates, regulations, and subsi-
expensive, inefficient, and poorly adapt-
dies. On the other hand, with a few conspic-
ed to an economy no longer built on
major problems,
uous lapses, Senator McCain leans toward
lifetime employment--a system that
and another
deregulation and free market approaches to
exposes Americans to insecurity and
health care reform.
possible destitution.
17 percent see
--Sen. Barack Obama1
The results of these policies are likely to be
it as being
very different for the American health care
"in crisis."
system. As Harvard University health profes-
Controlling health care costs will take
sor Robert Blendon puts it, "It is one of the
fundamental change. Nothing short of
biggest philosophical debates we've had in a
a complete reform of the culture of our
long time."8 Voters this year will have a very
health care system and the way we pay
clear choice.
for it will suffice.
--Sen. John McCain2
Barack Obama
There is no doubt that voters see health
care reform as a major election issue, with
Senator Obama has said that if he were
polls generally showing it trailing only the
designing a health care system from scratch,
economy and the war in Iraq among voter
concerns.3
his preference would be for a single-payer sys-
tem "managed like Canada's."9 However, given
This interest stems from an overwhelming
dissatisfaction with the current state of the
both the infrastructure of the existing system
health care system. According to a November
and the political opposition to a single-payer
2007 Gallup Poll, fully 56 percent of Ameri-
system, he has proposed a less radical ap-
cans believe that our health care system has
proach while hoping that "it may be that we
end up transitioning to such a system."10
major problems, and another 17 percent see it
as being "in crisis."4 Virtually every aspect of
Obama's proposal is based on the concept
the health care system comes in for criticism.
of "managed competition." Originally devel-
Not surprisingly, given the amount of atten-
oped by Stanford University economist Alain
tion paid to the uninsured, "access to care" is
Enthoven, among others, managed competi-
seen as the biggest problem, with "cost" a close
tion leaves the provision of health care in pri-
second.5 But even the quality of health care,
vate hands, but within an artificial market-
long a strong suit of the U.S. system, comes in
place run under strict government control and
regulation.11 Insurers would operate much
for criticism, with 45 percent of voters believ-
ing that the quality of care is "poor" or "only
like public utilities. Risk management or
fair."6
underwriting would be prohibited, and the
Thus, it is not surprising that both Barack
government would have at least some say over
Obama and John McCain have offered de-
services provided and premiums. This is the
tailed proposals for health care reform.7 In
same concept that formed the basis for the
the broadest sense, both seek similar things.
1993 Clinton health care plan, Mitt Romney's
Both would increase the number of insured
2006 Massachusetts legislation, and Hillary
Americans (though both would fall short of
Clinton's 2008 campaign proposal.
universal coverage), and both seek to reduce
Obama also appears to break somewhat
the cost of health insurance and overall
with recent Democratic orthodoxy on health
health care spending. In fact, both make cost
care reform by making the reduction of health
control the highest priority of their plans.
care costs at least as central to his proposals as
2