Commonwealth Fund on candidates' proposals

The 2008 Presidential Candidates' Health Reform Proposals: Choices for America

By Sara R. Collins, Jennifer L. Nicholson, Sheila D. Rustgi, and Karen Davis
The Commonwealth Fund
October 2008

The presidential candidates' health care reform proposals offer fundamentally different visions of the future of health insurance in the United States. Both candidates propose reforms in which the health system would continue to be structured around private insurance markets, with a supporting role played by public insurance programs. But their plans diverge significantly on the way a reformed system should operate.

McCain would change the tax code to encourage people to buy coverage through the individual insurance market and effectively loosen state rules governing the sale of insurance by allowing people to buy policies across state lines. Obama would encourage the continuing participation of employers in the health insurance system, expand eligibility for Medicaid and the State Children's Health Insurance Program (SCHIP), and create a new insurance market "exchange" -- with consumer protections, choice of public and private health plans, and income-based premium subsidies -- that would largely replace the individual market.

According to one estimate... in 10 years McCain's proposal would reduce the number of people who are uninsured by 2 million out of a projected 67 million. Obama's plan would reduce the number of uninsured people by 34 million in 10 years.

Executive Summary:

Full Report:


By Don McCanne, MD

So these are the "choices for America." We currently have 46 million people who are uninsured. After ten years of McCain's plan, we would have 65 million uninsured, but ten years of Obama's plan would leave only 33 million people without insurance. Only 33 million!?

The phrase, "both candidates propose reforms in which the health system would continue to be structured around private insurance markets," should set off deafening alarm bells and sirens. Schemes designed around U.S.-style private insurance markets can never achieve our goal of affordable health care for everyone.

Some say that we could do it if we required everyone to participate through individual and employer mandates. With an average family policy now priced at $12,600, not including deductibles and copayments, it is unrealistic to require individuals and small businesses to purchase coverage and health care with money that they do not have. Even Sen. McCain understands that the government is going to have to ante up, but that alone is still not enough since his proposal would leave 65 million uninsured.

With a national health expenditure of $2.4 trillion, we already have enough to fund a universal risk pool that would pay for all necessary services for absolutely everyone, but only if we were to do it through a single payer national health program. If we were to attempt it using private plans that were truly effective in preventing financial hardship, and that had government subsidies that would make the premiums affordable, the inefficiencies would add close to half a trillion dollars to our national health care bill, and too many individuals would still fall through the cracks.

So what about choices for America? Which candidate? Or which health reform proposal?

In a September 30 interview with the Des Moines Register editorial board, Sen. McCain provides us with some insight to these choices: "I've always been a free enterprise person who thinks that families make the best choices for themselves and their future. That's a dramatically different philosophy than my Democrat friends, in my view, who think that government is the answer. Sen. Obama wants to create a huge health care bureaucracy for America."

Sen. Obama has said that, if starting from scratch, we would create a single payer system. That's the health reform proposal that Americans should choose if we're really serious about including absolutely everyone in an affordable program. And which candidate do you think would approve this message?

Video of Sen. McCain's Des Moines Register interview: