AT THE MOMENT, the precise numbers and costs of the health care reforms proposed by President Bush and Sen. John F. Kerry are the subject of angry campaign rhetoric. But the principles of the reforms are not in dispute, nor is there much doubt that the proposals are very different.
In a certain sense, comparing the two is a bit like comparing apples and oranges. To be more precise, it's like comparing little apples with big oranges, since the president is proposing to spend a much smaller amount of money on providing coverage to far fewer people. At the heart of his proposal lies a plan to make it easier for individuals to pay for their health insurance themselves using a system of health savings accounts, coupled with high-deductible health plans. In plain English: This would allow some consumers to buy their own plans and pay their own initial costs using refundable tax credits, with more expensive or catastrophic care being paid by the insurers. It would also allow small businesses to get tax deductions for contributing to their employees' individual health insurance policies.
This proposal would be useful to relatively healthy people, and could lead to some savings, as consumers shop for the best deals on doctor visits and minor procedures. As we have written in the past, health savings accounts might also turn out to be the first step in the direction of portable, individual insurance, not tied to employment, which is a good thing. But the idea, as developed so far, is a relatively narrow change. The Bush proposals do not, for example, do much to help the chronically ill, or to halt the spiraling costs of chronic illness.
Mr. Kerry's proposals, by contrast, are broader and more expensive, and they would cover significantly more of the uninsured -- although, contrary to the president's campaign rhetoric, they do not constitute a government takeover of American medicine. In essence, Mr. Kerry proposes three changes: to extend Medicaid and other kinds of state coverage to a larger group of people; to give companies that cover all of their employees the option of having their catastrophic care costs reinsured by the government; and to allow individuals and employees of small companies to join the Federal Employees Health Benefits Program, which offers a wide range of choices.
An important advantage of Mr. Kerry's plan is that it builds directly on the current system. Many of the nation's governors have tried extending the reach of Medicaid before and thus have experience doing so. Many of the nation's employers are more likely to keep offering health care if they can expect help with their catastrophic costs or if they can become part of the larger, federal insurance pool. These are not ideas that will unsettle people or change the way that most of the insured get their health care. If, in exchange for paying catastrophic costs, the government can require company health plans to do a better job of managing chronic illnesses -- the failure to do so being the largest source of soaring costs -- Mr. Kerry might achieve some savings too.
The disadvantages of the Kerry plan are also clear: the cost to the taxpayer and the absence of any more radical cost-cutting mechanism. On balance, though, Mr. Kerry's instincts are closer to our own: Rather than allowing the problem of the uninsured to fester, and place an ever-greater burden on hospitals and doctors -- which would ultimately lead to higher insurance premiums for everyone -- it is better to look for more ways to cover more people. The complexity of Mr. Kerry's health care proposals surely makes the lives of his speechwriters difficult, but we admire its combination of pragmatism and ambition.
This is one in a series of editorials comparing the records and programs of the presidential candidates on important issues. Others can be found at www.washingtonpost.com/opinion.