Special Report

McCainCare vs. ObamaCare

McCain not conservative enough? Consider the alternative.

By 5.1.08

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Conservatives like to kvetch about John McCain, and not without reason. McCain has, over the years, given us plenty to complain about. Not only has he sided with the forces of darkness on immigration, the Bush tax cuts and the interrogation of terrorists, he is responsible for one of the most egregious attacks on political speech ever devised -- The Bipartisan Campaign Reform Act of 2002. Many conservatives are therefore uncomfortable with McCain as the Republican standard bearer in the upcoming Presidential election.

McCain will not, however, be running against Ronald Reagan or William F. Buckley in November. His opponent, barring a party-wrecking decision by the Democrat superdelegates, will be Barack Obama. And, on his most heretical day, McCain would be a better President than the Senator from Illinois. McCain's conservatism is indeed less-than-pure, but he is a conservative. Obama, his facility with innocuous-sounding bromides notwithstanding, is a classic nanny-state liberal.

Nowhere are the ideological differences between McCain and Obama more obvious than in their respective approaches to health care reform. McCain would emphasize consumer choice, markets and tax reform, while eschewing government-run health care. As he put it on April 28, at the launch of his "Call to Action" tour, "I am convinced that the wrong way to go is to turn over your lives to the government and hope it will all be fine." Obama, on the other hand, places considerable faith in the state, favoring the shopworn tools of big-government liberalism: central planning, oppressive bureaucracy, and the creation of new entitlement programs.

McCain's emphasis on consumer choice is an important feature of his approach to health care inflation. Recognizing that exorbitant health coverage premiums are caused in large part by the absence of a national market in which insurance carriers compete with one another for business, McCain would allow consumers to buy health coverage across state lines. He believes that "Millions of Americans...making their own health care choices again," would create an environment in which "insurance companies could no longer take your business for granted, offering narrow plans with escalating costs." McCain would augment this consumer-driven aspect of his cost control strategy by using tort reform to reduce defensive medicine, the annual cost of which is estimated at $210 billion.

This need for tort reform is also recognized -- rhetorically -- by Obama. He has said publicly that "Anyone who denies there's a crisis with medical malpractice insurance is probably a trial lawyer." Unfortunately, his reform plan contains no serious provision for dealing with the problem. In fact, it doesn't contain any serious cost control proposals at all. It does, however, contain a provision that would gut Medicare Advantage, a market-based alternative to traditional Medicare very popular among low-income and minority retirees. The worst feature of this ill-considered proposal is that it would dramatically reduce access to care for elderly patients in rural areas where few physicians can afford to accept traditional Medicare. This is particularly ironic coming from a candidate who makes much of his commitment to increasing access to care.

ACCESS TO CARE and the closely related issue of the uninsured constitute another area on which McCain and Obama have very different views. McCain's plan would address these issues by decoupling health insurance from employment. This would be accomplished by replacing the current tax break for employer-provided health coverage with tax credits for individuals, and allowing employees to take their insurance with them when they change jobs. McCain is against a federal law requiring people to buy insurance, describing his position on such mandates as follows: "I'm not going to mandate that every American have health insurance. I'm not going to mandate that every American have a home ... but I'm going to make them affordable and available." He is likewise opposed to mandates requiring businesses to provide health coverage for their employees.

When Obama talks about the uninsured problem he sounds similar to McCain. He has often said, "the reason people don't have health insurance isn't because they don't want it, it's because they can't afford it," and he is nominally against health insurance mandates for adults. But his actual plan would clearly deal with the problem by imposing the will of the federal government on consumers, businesses and insurance companies. Obama's website advises that he will "require all children to have health care coverage," while forcing employers to provide health insurance or "contribute a percentage of payroll toward the costs of the national plan." The "national plan" to which this passage refers is the new federal insurance program that Obama would create to augment the expanded Medicaid and SCHIP he also envisions. Any private insurance carrier that survives competition with this cut-rate combination would be required to cover "children" up to age 25.

These newly minted "children" will, of course, be concerned about the quality of care they receive, and this issue is also addressed by the two candidates. McCain's approach to quality is consistent with his emphasis on consumer empowerment. He would not only require transparency from hospitals and physicians in the areas of cost and price, he would insist that providers report outcomes. In the service of this last goal, he would establish uniform national measurement standards. McCain also support the "medical home" concept, "We must move away from a system that is fragmented...toward one where a family has a medical home, providers coordinate their efforts...and where the focus is on affordable quality outcomes."

OBAMA'S APPROACH TO QUALITY is likewise consistent with his own governing philosophy. As the centerpiece of his quality initiative, he would establish yet another federal bureaucracy. His web site describes this entity as "an independent institute to guide reviews and research on comparative effectiveness." His quality program also includes a feature much in vogue among left-leaning health care reformers -- an initiative to eliminate outcome disparities: "He will also challenge the medical system to eliminate inequities in health care through quality measurement and reporting, implementation of effective interventions such as patient navigation programs, and diversification of the health workforce." Obama would, in other words, unleash the diversity police on the health care system.

No such utopian fantasies mar McCain's reform proposals, but his plan is by no means free of bad ideas. One ill-considered idea involves his intention to allow drug reimportation from Canada and other nations. If implemented, this would not merely import foreign price controls, it would stifle pharmaceutical innovation. As James Antle explains, "Bringing each new drug to market costs an average of $800 million and may take between a dozen and fifteen years to complete....Without the prospect of reaping a windfall, companies won't tie up so much capital in a process where successes are rare." Even worse, the policy wouldn't accomplish its basic goal. The CBO has estimated that drug reimportation wouldn't save the American public very much money.

McCain's embrace of drug reimportation serves as a reminder that his is an adulterated variety of conservatism that will continue to irritate ideological purists. However, purity isn't one of our choices this year. The actual candidates we will find on the ballot when we go into the voting booth will be John McCain -- a conservative given to occasional bouts of heresy -- and Barack Obama -- a classic nanny-state liberal. On health care, as well as a variety of other issues, a President McCain will be something of an irritant. A President Obama, by contrast, would be an unmitigated disaster.

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About the Author

David Catron is a health care revenue cycle expert who has spent more than twenty years working for and consulting with hospitals and medical practices. He has an MBA from the University of Georgia and blogs at Health Care BS.