The Health Care Divide

On many issues, presidential candidates rush to the middle. But not on health care. McCain and Obama offer opposing prescriptions to treat the health care crisis, but how will it shake out for emergency physicians?

On many issues, presidential candidates rush to the middle. But not on health care. McCain and Obama offer opposing prescriptions to treat the health care crisis, but how will it shake out for emergency physicians?

The confetti and streamers have long been swept from the floors of the Democratic and Republican national conventions. The way I see it, there’s a candidate for everyone, from the angsty youth (Obama) to patriotic veterans (McCain), from the foreign-policy guys (Biden) to the independent hockey moms (Palin). All are very intriguing, but before you pull that lever or punch your chad, ask yourself this question: How will each candidate impact emergency medicine?

While you could hinge your vote on any number of specific issues, there are two that will ultimately have the biggest effect on your life: health care and the economy. According to a study published in August by The Commonwealth Fund, 41% of working-age Americans are now struggling to pay medical bills and have accumulated personal debt solely due to medical care. According to statistics published by the National Coalition on Health Care, in 2007, health care spending in the United States reached $2.3 trillion, and was projected to reach $3 trillion in 2011. Health care spending is projected to reach $4.2 trillion by 2016 when it will account for 20% of the GDP up from 16% in 2005 as the population grows and ages. Forget the societal implications of universal and better health care, from an economic perspective alone, health care is big business and will continue to be so for a long time.

Today, both Obama and McCain are claiming to be the candidate for “change,” which is the standard political battle cry when the voters are unhappy with the status quo. Put simplistically, McCain promises smaller government and more personal choices while Obama promises bigger government and more federal programs. McCain promises to work in a bipartisan fashion, something he has taken heat from Republicans for over the years (McCain has historically voted with the Republican leadership only 83% of the time). Obama promises similar bipartisan dealings, but he has yet to do so on a major legislative issue. Obama has rarely broken ranks during his three years, voting with the party leadership 97% of the time.

As with every candidate for political office, both men promise more than they can realistically deliver. Let’s face it, that’s how you get elected…convince enough people that you will deliver on “their” issue. So what have McCain and Obama promised to deliver on health care?

The Basics: Sen. Obama states that every “American” “has the right to affordable, comprehensive, and portable health coverage.” Obama promises to establish a new public insurance program for Americans who do not qualify for either Medicaid or SCHIP, nor have access to employer based insurance. Obama states that he would create a “National Health Insurance Exchange” to help individuals and businesses that want to purchase private insurance directly. Obama would require that all employers contribute a “meaningful” share (whatever that is) to either the cost of health care insurance for employees or to the cost of the public plan. Lastly, in regards to universal coverage, Obama would mandate that all children have health care coverage, but not all adults. Obama promises to pay for his plan by subsidizing the cost of catastrophic care, increasing disease management and coordination of care, investing in health IT systems and increasing competition in the insurance and drug markets.

Thumbs Up: More than any other specialty, emergency medicine could stand to benefit from a more “universal” plan. Shouldn’t we get paid for taking care of everyone on a 24/7/365 basis? Imagine a day when the concept of a “Self Pay” patient doesn’t exist.

 

Thumbs Down: What Obama doesn’t say a whole lot about is the cost of implementing his plan to provide “universal health care coverage”. The Obama campaign estimates the cost will be $50-65 billion PER YEAR.  Other more conservative estimates are much higher than this, over $100 billion…and yes, this is a lot of money, even for the federal government. This doesn’t include the $50 billion he has committed to invest in health care IT over the next 5 years. And who is going to pay that high price tag? “The rich.”

The “rich” for Obama mean insurance companies, drug companies, and oh yeah, emergency physicians. According to a Brookings Institute review of the candidate’s tax plans, under Obama, Americans making more than $117,535 would pay an additional $6,770 in taxes (about a 5.8% increase), and you can do the math if you make more than the base number. If you believe in big government, lots of socialized programs handing out money, and higher taxes for “the rich” then Obama is your man. Oh, and if you’re interested in tort reform, forget it.

STATED GOAL:
Provide affordable and high-quality universal coverage (including mandated coverage for children) through a mix of private and expanded public insurance.

McCain’s Plan

The Basics: Sen. McCain has campaigned on a platform of reforming the health care system by restoring control of health care decisions to patients and ensuring they have more choices. McCain believes in providing patients more opportunities to purchase health care insurance. If families are not covered by employer-based health care insurance or if they opt out of that system, they would be provided with a $5,000 tax credit ($2500 for individuals) which could be used to directly pay a private insurer for health care insurance. McCain also promotes making health care insurance portable and increasing the use of Health Savings Accounts (HSAs). McCain states that he will work with state governors to develop a Guaranteed Access Plan (GAP) to develop a best practice model for providing insurance to those who have traditionally been uninsurable, those individuals without prior group coverage or with pre-existing medical conditions. McCain promises to pay for expansion of coverage through a series of cost saving measures including lowering drug prices through safe re-importation, chronic disease management, improved IT coordination, tort reform, and Medicaid and Medicare reform.

Thumbs Up: Proponents of a free market health care system can get behind McCain’s tax-credit plan, which offers consumers a chance to have greater control over the health care marketplace with less interference from the federal government.

Thumbs Down: I’m not sure how the insurance tax credit math works since most family health care insurance policies are running about $14,000 per year. And while all the mechanisms to raise funds sound good, there’s a whole lot of detail that we’re not seeing, like how long it will take to really see any financial benefit from any of those items and how do we pay for them now. Interestingly for emergency medicine, McCain also promotes increased access and convenience of care, and specifically touts that “government should promote greater access through walk-in clinics in retail outlets.” Not exactly a “warm fuzzy” for those of saving lives in the ED on a 24/7 basis.

STATED GOAL:
Provide access to affordable health care for all by paying only for quality health care, having insurance choices that are diverse and responsive to individual needs, and encouraging personal responsibility

In the booth

Okay, now you have the inside scoop on the candidates. You can choose bigger government that covers everyone, but which will come out of your pocket, or you can vote for smaller government, every man for himself, and lower taxes. OK, so that’s an uber-simplification, but you get the idea. Take a close look at the candidates for yourself. Listen to the debates and see what they are saying about where they will take health care. Your livelihood could be in the balance.
 

Dr. Cirillo is the Director of Health Policy & Legislative Advocacy at Emergency Medicine Physicians, LLC,. He is also the Republican candidate for Rhode Island State Representative, District 33.