How They Would Change Health Care: McCain and Obama

Washington Post staff writer Amy Goldstein was online Wednesday, Oct. 29, at 3 p.m. ET to discuss her articles on how the candidates would change the current health care system.

How They Would Change Health Care: McCain's Proposal for High-Risk Coverage Is Similar to a Program in Minnesota and and How They Would Change Health Care: Obama's Approach Emulates Massachusetts's Except for Mandate on Covering All Adults

The transcript follows.

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Amy Goldstein: Hi, everyone -- thanks for joining me to talk about health care, an issue on which this year's presidential candidates have intriguingly different visions for the future. We have lots of questions waiting, so let's get started.

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Princeton, N.J.: Both Obama and McCain propose to put Band-Aids on a tuberculosis patient when other countries are using antibiotics. Neither does anything to eliminate the basic inefficiencies in our system. Consider the $200 billion per year wasted by physicians filling out thousands of different insurance forms, the $100 billion per year wasted by the 15 percent overhead of private plans, and the incalculable money wasted by high drug prices set by companies that spend 11 percent on research and 34 percent on "marketing." It doesn't fix the basic flaw that the rules of our system are set by the insurance companies, the sole interest of which is to make money, not to give efficient and competent medical care.

I implore you to compare our system with the single-payer systems of other wealthy countries. They get better health care as measured by every important public health statistic and pay less than half per patient while doing so. You probably will say such a system is impossible in the U.S., but similar things were said about Social Security and Medicare. One thing is sure: We never will get a reasonable, efficient health care system if the politicians and the media refuse to see a solution that is staring them in the face.

Amy Goldstein: Thanks for the question. It shows both how much frustration there is with the current health care system, and how much of a difference of opinion exists regarding how to improve it. Neither Sen. Obama nor Sen. McCain say they would pursue a single-payer system, but that leaves plenty of room for them to disagree with one another. Broadly put, Obama favors a more regulated health insurance industry -- with an expansion of both public and private coverage options -- while McCain thinks a free-market approach is better, with the government giving people tax credits and eliminating workers' ability to exempt the value of health benefits they get through their jobs from their taxes.

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Reston, Va.: I've read conflicting stories about whether or not Obama's plan would fine parents who do not insure their children. In 2007, Obama told a Des Moines paper that he would. He dodged the question at the debate. Then in mid-October, a campaign spokesperson dismissed the question by saying they don't think it will be necessary because everyone would sign up for coverage. So what's the real story -- fine or no fine?

And on the McCain front ... if he were to become president, given what probably will be an even more partisan environment, do you think his plan would stand any chance of passing?

Amy Goldstein: To answer your second question first, how much chance either candidate's health care plan stands of passing in Congress is an open question, particularly in a deteriorating economy. The same political forces that have hindered broad health care changes in the past -- different views of the insurance industry, business and consumers for instance -- inevitably would resurface. On the other hand, there is increasing public frustration with the state of health care, and that would provide momentum.

As for Obama's idea of requiring that all children be insured, his campaign has been a little vague about how that would be enforced. That is one of many examples in which both their plans, detailed as they are, contain unanswered questions.

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Arlington, Va.: Amy, thank you for these really pointed, helpful articles. One often hears things about "digitizing medical records" or "electronic medical records" during presidential campaigns, but so far (like improving education) this has never come to pass. Doctors are historically reluctant to adopt online or electronic records, and then there are the privacy issues. Has Obama actually put forth any concrete information about how he would really implement this, or is it just so much campaign fluff?

Amy Goldstein: Thanks for the compliment. As for electronic medical records, both Obama and McCain regard the conversion from paper to electronic records as a way to make health care more efficient, not to mention a way potentially to cut down on medical errors. This is another area, though, in which the nitty-gritty details of their proposals haven't been fleshed out.

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Philadelphia: What is the Obama campaign's rationale for not having a mandate?

Amy Goldstein: The question of a mandate -- that is, whether the government should require everyone to have insurance -- was a main difference during the Democratic primary between the health care plans of Sens. Obama and Clinton. Obama has said that all children should be covered, but he would stop short of a mandate for adults. The health policy scholars and others on whom Obama has relied to hone his thinking about health care essentially say that lots of additional people would get insurance under his plan, even if the law doesn't make them do it.

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Annandale, Va.: One of the most critical elements missing from analysis of the McCain plan is the fact that his goal is to get people out of group health care plans and purchasing health insurance as individuals. This seems to me to be one of the biggest flaws in his plan. Group purchases bring size-able discounts that individuals don't get, and they also serve to enable people with pre-existing conditions to get insurance that they couldn't get on their own. This represents a huge windfall to the insurance companies and a huge disadvantage for consumers. Have you looked into this issue?

Amy Goldstein: You raise an important question. Putting it another way, whose approach to insurance would do the most to make coverage affordable to the broadest number of people? In Sen. McCain's view, by stopping tax exemptions for employer health benefits and giving tax credits to individual families, he would be promoting competition. He argues this would happen because individuals could choose to keep employee benefits or buy coverage from big health plans based anywhere in the country. Critics say, though, that the switch might encourage young, healthy workers to defect from employer coverage, leaving those pools older, sicker -- and more expensive -- patients. Plus, critics say, buying coverage across state lines would weaken the effect of state insurance regulations. It's a complicated question, this matter of insurance pools.

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Rockville, Md.: Two questions: You used to cover health care for The Washington Post extensively, but I hadn't seen your name associated with many recent health-care articles until now; will you now be the main health-care reporter for The Washington Post? Also, your story on Minnesota didn't discuss whether or not Minnesota requires health plans to be nonprofits in order to offer insurance in the state. Is this true, and would it affect the viability of a high-risk pool in that state?

Amy Goldstein: What a good memory. For years, I covered health care for The Post full-time. These days I tend to dip in and out of a variety of social policy topics -- including this one, which continues to interest me a lot. I still have colleagues in several parts of the paper who write about health care as a steady beat.

As for Minnesota, the high-risk pool is for people the private insurance industry does not want because they are sick (and thus expensive to insure). The pool, called the Minnesota Comprehensive Health Association, is run by a nonprofit corporation, which in turn contracts with a private insurer to administer the benefits.

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Evanston, Ill.: A main problem with health care is the rampant inflation. How much of this inflation comes from the way in which government presently funds health care?

Amy Goldstein: Health care inflation is a big and persistent problem, and people can get into big disagreements about the governments' role in it. A couple quick of random thoughts about this: For what it's worth, the administrative costs in the big government insurance programs, Medicaid and Medicare, historically have been lower than in most private insurance companies.

Also, ever since Congress passed an important Medicare law in 2003 that added a prescription drugs benefits to the program, there has been partisan bickering about whether that law allowed private health plans to get paid too much by Medicare for insuring people 65 and older. Both Sens. McCain and Obama say, to different degrees, that they have some sympathy for lowering those payments. That, though, isn't the entire solution to medical inflation.

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Washington: Thank you, thank you, thank you for covering these two health plans in a thoughtful way! How long did you have to work on these stories?

Amy Goldstein: I'm glad you found the stories useful. Altogether, I worked on them for nearly four weeks, including visits to Minnesota and Massachusetts to get a first-hand feel for how things are going with health care there. Although nowhere in the country is trying precisely what Sens. McCain and Obama are proposing, I thought those places offered the closest real-life analogy to each candidate's plan. Besides, each place is, in a way, a kind of best-case scenario, so I thought it would be especially interesting to learn -- and tell readers -- what is going right and wrong in that kind of environment.

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Boston: Essentially it seems to me that McCain's plan is a better deal for healthy people and Obama's plan is a better deal for sick people. Is that a fair characterization?

Amy Goldstein: Some people would agree with you, but not everyone. That's what makes the health care debate interesting.

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Boston: I like the Obama plan because he would force companies to not discriminate based on pre-existing conditions, but I do wonder if the insurance companies wouldn't try to work their policies to be unfriendly to pre-existing conditions so those people would pick another company. Is there any evidence for this?

Amy Goldstein: This has to do with an arcane-sounding term called "guaranteed issue," which basically means that insurance companies cannot deny anyone coverage or charge them more if they already are sick. This strategy is, as you point out, part of Sen. Obama's thinking. It has been tried only in a few states -- New York, New Jersey and a couple more, in addition to Massachusetts. One big argument about guaranteed issue is whether it needs to be done in conjunction with a requirement that everyone have insurance. The argument here is that, if they know they can get covered whenever they need it, people might wait to look for insurance until they get sick. Of course, that really would drive up the cost of insurance. Whether this argument is right, like so much in health care, is a matter of debate.

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Charlotte, N.C.: One of the reasons I am a fired-up Obama volunteer is McCain's plan to eliminate the employer deduction for health plans. I can just hear the great sucking sound as employers dump coverage for their employees. I have a disabled wife, and I can just imagine how little that $5,000 will go toward buying a insurance plan on the individual market.

Amy Goldstein: Thanks for pointing out, yet again, that health care is an important issue among voters -- and a very personal one. Sen. McCain and people who agree with him say that employers would not rush to drop coverage for a variety of reasons, including that health benefits are necessary if companies are to continue to attract a good workforce. McCain says the $5,000 tax credit would be a good deal. Others have pointed out that the average cost of group insurance in the United States is, if I'm remembering correctly, about $12,000. Another way, in other words, that there are strong, competing views.

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Huntsville, Ala.: Isn't that the problem, though, many more people getting insurance through the government? The examples of Tennessee, Hawaii and Massachusetts is so many people getting health insurance that the plans become unaffordable. The only way to cut cost is to reduce benefits, but there is always a judge who won't allow that. It would seem that either the government should provide health care to everyone, or should find a way for the current system to improve access.

Amy Goldstein: As your question implies, there is a fundamental tension between expanding access to health care and reducing costs. Just to give you an example from how that played out in Massachusetts, people heavily involved with implementing the health care changes there freely acknowledged to me that the consideration of costs really was subordinated in the 2006 state law that set the reforms in motion. It was hard enough, they told me, to enact a complex law expanding coverage. Dealing with costs at the same time would have been politically impossible; now they are going back to try to grapple with the cost question. It's unclear so far how well they will succeed.

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Amy Goldstein: Unfortunately, I see that our hour is over. Thanks for all your impressively well-informed and passionate questions, and sorry that I couldn't get to them all.

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