March 14, 2008 -- Should everyone in America have access to health insurance? If so, should you be required to get it?
Beneath all the complexities, the presidential health care debate really boils down to those two big questions. And how you feel about the answers might tell you a lot about which candidate you think can solve the nation's mounting health care problems.
As for question one, Democratic candidates Hillary Clinton and Barack Obama both answer "yes." Each has a plan leading to "universal health care," a system in which everyone has medical coverage. For McCain, the answer is both "yes" and "no."
McCain says everyone should have access to coverage in principle, but his plan doesn't guarantee it and won't try to. He believes that market-based forces can work to bring down health care costs so that eventually people can afford to buy it.
But before you think it's just Clinton and Obama vs. McCain when it comes to health care, think of question two. Clinton says that making sure everyone is covered is a critical ingredient to reforming the way insurance companies cover health care. That's why she says that everyone should be required to get coverage.
Obama agrees, but only up to a point. He says parents should be required to make sure their kids are covered. Then once insurance reforms help bring down costs, everyone else will eventually have to get coverage too.
Obama has attacked Clinton for calling for an insurance mandate. While that is often a dirty word in politics, Clinton and her advisors say it's necessary.
"It's important from the start to make sure that coverage is universal," says Katherine Hayes, a vice president at Jennings Policy Strategies, which advises Clinton's campaign on heath issues.
Unless everyone has coverage, insurance companies can still seek out the healthiest people to cover. That leaves older and sicker people -- the ones who need coverage the most -- out of the loop, Hayes said at a Capitol Hill forum on the candidates' health plans sponsored by the Alliance for Health Reform.
The practice is called "cherry-picking," and both Clinton and Obama say it needs to be done away with.
"Both call for individuals to acquire coverage when it becomes affordable," says Gregg Bloche, a professor of law at Georgetown University and an advisory to Obama's campaign.
But Obama wants to give reforms time to work before requiring coverage. Both he and Clinton want to form purchasing pools to make insurance cheaper, and to work to decentralize health care from hospitals and traditional clinics so that it's easier to access.
They both also want to provide tax credits to help small businesses buy coverage for workers, and provide subsidies to help people get coverage if they can't afford it themselves.
McCain and the Market
McCain wants to expand coverage, but thinks the best way to do it is by going after cost first. He wants to give individuals more tax incentives to buy coverage on their own instead of through their workplace. He would also push tax credits -- $2,500 for individuals and $5,000 for families -- to encourage people to buy coverage.
"He doesn't have to do so at a price that is inordinately high to the taxpayer," says Raissa Downs, a partner at the Tarplin, Downs, and Young law firm in Washington and a health policy advisor to McCain's campaign.
Where They Agree
McCain, like Clinton and Obama, favors a stronger role for primary care doctors, and a much bigger emphasis on preventive medicine as a way to improve care and cut costs. And all three say they want to shake up the way Medicare and Medicaid pay for care, by paying more when doctors and hospitals provide good quality care, instead of just paying for every test and treatment the way they do now.
All three also say they want a much bigger role for health information technology like electronic medical records and virtual information sharing between doctors.
Of course, the similarities don't mean that Democrats and Republicans will start getting along about how to change the $2 trillion-per-year health system. Obama and Clinton are still fighting it out in the primaries, often grappling over their highly similar health plans.
Hayes, who advises Clinton, says Democrats will be united once they choose a nominee.
"Then we can turn our focus to attacking Sen. McCain's plan," she said.