Barack Obama was in St. Louis on Tuesday to discuss health care reform. That should come as no surprise. Most polls show that voters see health care as one of the top three issues in the 2008 presidential election, trailing the economy and the war in Iraq.
But while Americans seem to want some kind of reform, most have no idea what kind. A 2007 Gallup Poll showed more than half of Americans support every suggested health care reform, from the most market-oriented policies to total government control, even when those policies were mutually exclusive. More than half of voters said yes to a government-run single-payer system. But an even larger majority – more than 77 percent – favored "reducing government regulation of insurance."
Poll numbers seem to argue in favor of proposals for a radical overhaul of the system, but candidates should be wary of going too far – particularly if their proposals appear to threaten the insurance coverage people have today. Because while voters are critical of the system as a whole, they tend to be much happier with their own care. Another Gallup Poll, taken last December, shows that 88 percent of Americans believe the quality of their own care is "good" or "excellent," and 70 percent believe the same of their own insurance coverage.
According to Gallup, roughly 81 percent of voters support a requirement that employers provide health insurance to their workers — a proposal supported by Democratic presidential nominee Barack Obama. Yet 86 percent want to do away with employment as a prerequisite for health insurance, along the lines of a proposal by Republican nominee John McCain. Two-thirds also agree with McCain's call for a health care tax credit, but 77 percent agree with Obama that we should increase subsidies for low-income Americans to help buy insurance, and 54 percent would repeal the Bush tax cuts to do it.
Voters are saying that almost anything is better than the status quo. The candidates offer very different visions of the direction that reform should take, but in the broadest sense, both seek similar outcomes. Both would increase the number of insured Americans (though both would fall short of universal coverage). And both seek to reduce the cost of health insurance and overall health care spending. Significantly, in fact, both make cost control the highest priority of their plans.
However, the candidates differ greatly in how they would achieve their goals. Obama's approach relies heavily on government mandates, regulations, and subsidies. He would force employers to provide coverage for their workers and parents to purchase health insurance for their children.
Obama would significantly increase regulation of the insurance industry, establishing a standard minimum benefits package, requiring insurers to accept all applicants regardless of their health, and prohibiting risk-rating of insurance premiums. This would dramatically increase the cost of insurance for the young and healthy. Obama would also offer a variety of new and expanded subsidies to middle- and low-income Americans.
In contrast, McCain emphasizes consumer choice and greater competition in the health care industry. He would replace our current system with one under which the tax exclusion for employer-provided insurance became a refundable tax credit for individuals, which they could use to purchase plans of their own choosing. McCain would sharply deregulate the insurance industry to increase competition, and attempt to shift the way health care is financed from episodic care (X number of trips to the doctor's office) to outcome-based criteria (the patient is cured).
Historically, Democrats have enjoyed an electoral advantage on health care, and this year seems no different. When asked which party they would prefer to see handle health care reform, voters prefer Democrats, 52 to 36. But when it comes to specific ideas for reform, voter preferences are far less clear, which makes for an open debate.
The results of McCain's and Obama's policies are likely to be very different for providers, patients, and taxpayers. It's anybody's guess how they'll develop. But as November approaches, voters will reach a fork in the road, and as Yogi Berra says, they'll take it.