Doctors demand specifics on candidates' health care plans

The advantage of being a definitive presidential nominee while the other party continues to fight out the primary is that you get a head start on general election campaigning. The disadvantage, as Sen. John McCain's campaign learned at Internal Medicine 2008, is that the other party may double-team you.

The McCain campaign, as represented by Thomas Miller, a fellow at the American Enterprise Institute, faced other challenges during the session “Reforming the Health Care System: Positions of Leading Presidential Contenders.” Former College President Whitney W. Addington, MACP, spoke on behalf of Sen. Barack Obama's campaign, and another physician, Irwin Redlener, MD, of the Columbia School of Public Health, represented Sen. Hillary Clinton.

The Democratic representatives were positive about each other's plans and in agreement on their underlying similarities. They were not so enthusiastic about Mr. McCain's proposals. “There is a fundamental problem with the McCain plan. We first must keep in mind the plight of the uninsured,” said Dr. Addington.

In addition to criticizing Republican plans for health care, the Clinton and Obama proxies did get into some debate on their usual cause for disagreement—mandating coverage. Dr. Addington offered some new insight into the logic behind Mr. Obama's decision not to mandate insurance coverage for adults (which I had previously heard justified on grounds of political expediency). “The problem with mandates is they are unfair to poor Americans,” he said.

There was some discrepancy between the statistics he offered and those provided by Dr. Redlener (on whether insurance premiums under the new system would be capped at 5% or 10% of income), but basically Dr. Addington argued that forcing low-income families to buy coverage from the start would place an unreasonable burden on them. “Senator Obama wants to lower the cost of health insurance first but will consider a mandate if necessary after costs might be reduced,” he said.

Dr. Addington also dismissed concerns about the possibility of a significant percentage of the population choosing not to buy coverage if it was optional. “Senator Obama and his staff do not feel that there are many people who don't have health insurance on purpose. The main reason they don't have insurance is that they can't afford it.”

Mr. Miller introduced Mr. McCain's ideas into the discussion about covering the uninsured with an innovative explanation of his candidate's proposed individual tax credits for health insurance. “Forfeiting that tax credit—$5,000 per family, $2,500 per individual—that's kind of the equivalent of a flip-side penalty which says that if you fail to get coverage, that's the money you left on the table and is in effect a penalty,” Mr. Miller said.

Put that way, the idea didn't sound that far from Mrs. Clinton's proposal to penalize those who failed to buy coverage (acknowledging, of course, that their plans are otherwise dramatically different). In general, Mr. Miller's objections to the Democratic plans seemed more pragmatic than ideological.

“You hear a lot of things that are at this stage more aspirational than operational,” he said. “They are going to be much more difficult to carry out in practice. The reality, as Senator Clinton discovered in ‘93, is that you can design the best plan, but it has to work out there with everyone else's plans.”

Dr. Redlener, who advised the Clintons during their first attempt at health care reform, was undaunted. “Just because it's a complicated problem, it doesn't mean that we have to give up on it and assume we can't solve it,” he said. “The point is it has to be addressed.”

Mr. Miller also touted the lower cost of the McCain plan, and noted his candidate's more aggressive stance on malpractice reform, although he offered no promises in that area. “The current system is indefensible, but it's tough to legislate at the federal level,” he said.

Health care reform may be difficult, but evidenced by the session's capacity audience and active Q&A period, internists seem eager for the next president to give it a try.