by Maya Schenwar, January 23, 2008 –  In casting their votes for president this year, Americans rate health care as a top issue – second only to the war in Iraq. Each of the Democratic candidates claims to meet that concern with a plan to provide health insurance for “all Americans.” All of them have referred to their plans as “universal.” But experts are fuzzy on what “universal” means.

“The ‘universal’ is supposed to mean everybody,” said Dr. Robert Blendon, who directs the Program on Public Opinion and Health and Social Policy at Harvard University. “But it has come to include some slippage.” He estimates that the goal of the top candidates’ plans is about 97 percent coverage. None of their plans set a standard for the quality of the insurance that is provided.

The leading candidates’ proposals all include mandates: individuals are required to purchase insurance, employers are required to offer it and those who can’t afford insurance through their workplace will be provided for by government subsidies. The system assumes that all eligible parties will follow the rules and buy insurance – it’s available, not automatic; more affordable, but not free.

All the plans expand eligibility so that fewer people are turned away because of preexisting conditions.

“The three candidates’ plans are very, very similar,” said Don McCanne, senior policy analyst at Physicians for a National Health Care Program. “In Congress, these proposals would be the same bill.”

The main exception is one aspect of Barack Obama’s plan – he only requires insurance for children. Adults would continue under the current standards of the employer-based health care system, though, Obama promises, with much more affordable premiums and access to a greater variety of plans.

In contrast, “long-shot” candidate Dennis Kucinich would provide “single-payer” care: automatic, government-funded coverage, with no out-of-pocket charges.

The Case for Requirements

Why the similarities among the front-runners? Without a single-payer program, mandates are the only way to make close-to-universal care happen, according to Karen Davenport, director of health policy at the Center for American Progress. She likens it to the car insurance requirement: Americans are much more likely to purchase car insurance than they are to, say, invest in a 401K retirement plan, although the benefits of a 401K are clear. (Still, say critics, such a plan would never actually provide for all citizens. Fifteen percent of Californians don’t have auto insurance, despite the state requirement.)

In all three plans, the financial burden of purchasing insurance would be eased by subsidies from employers and the government.

However, none of the candidates has fully addressed the uncomfortable topic of what the penalty would be for those who don’t purchase coverage. Under the Massachusetts health care mandate enacted in 2006, the fine for noncompliance is one-half of an individual’s full insurance premium – a steep price for those who may have opted out because of financial constraints.

“The devil is in the details,” Davenport said. “Clinton and Edwards require insurance for all, but they don’t completely specify how it is going to be enforced.”

Inevitably, even with strict enforcement, individuals will fall through the cracks, according to McCanne. Some simply won’t be able to afford it. Although Medicare will stay in place, and low-income people will receive more subsidies than under the current system, many people with moderate incomes have high outside expenses that suck up the money they “should” be spending on health insurance. With only modest government support, they may not have the cash to pay for premiums.

Others don’t think they need it. Blendon points to young adults, who often assume they’re in good health and may refuse to buy insurance.

In Massachusetts, regardless of the requirement, only seven percent of uninsured individuals who are not eligible for free care have enrolled in insurance plans.

None of the top three candidates would extend insurance to undocumented immigrants.

Under any of them, the mandate system would involve a number of public and private insurance options, making the process – and the role of the government in that process – different for everyone. All three emphasize individual decision-making; Clinton even calls her proposal “the American Health Choices plan.”

However, a mixture of public and private plans, involving differing levels of government subsidies and requirements for employers, adds yet another layer of bureaucracy to the already-convoluted health care system, according to Rudolph Mueller, author of “As Sick As It Gets: The Reality of Healthcare in America.” Mueller commends the candidates for agreeing on a goal of universal coverage, but is wary of mandates – and of keeping the current employer-based arrangement in place.

“They’re making it way too complicated to handle for the average person,” Mueller said. “It leaves all the inefficiencies in the system. It relies on many different funding mechanisms and is not easily accessible.”

A Single Payer Solution?

Clinton, Obama and Edwards have all supplied a rationale for retaining a market-based approach to health care, with Obama – the only one who eschews universal mandates – leading the pack. He claims his plan will fuel competition, providing more options so that insurance companies will be forced to drive their premiums down, making health care affordable enough that everyone will buy it.

“What I see are people who would love to have health care,” he said during a November debate in Nevada. “They desperately want it. But the problem is they can’t afford it.”

However, according to McCanne, neither the mandate method nor the “affordability” method of achieving universal care addresses underinsurance, which presents an increasing dilemma as private insurance companies cut down on the procedures, prescriptions and types of service they cover. Consequently, the best plans are the most expensive, and those who can’t afford those plans end up with inadequate coverage. McCanne maintains this problem won’t disappear until the private health care system does.

The single-payer model has been floated on and off in recent years, most recently as the United States National Health Insurance Act, a bill proposed by Kucinich and Rep. John Conyers Jr. and cosponsored by 87 other Congress members. Its supporters assert that a single-payer system is the only route to 100 percent health care coverage.

“The nature of the private market is to try to compete based on premiums, so companies end up shifting more costs to the beneficiary,” McCanne said. “The Kucinich plan is fully comprehensive. Money no longer becomes a barrier to accessing health care.”

Underinsured individuals frequently behave like the uninsured, avoiding the doctor’s office until their condition is out of control, according to Mueller. They often stop filling their medications and refuse treatment, he said.

John Edwards’s plan includes a hope that his system would “evolve” into a single-payer model, and Obama said earlier this month that he’d opt for single payer if he were designing the system “from scratch.” Yet both dismissed the idea as too impractical and costly to implement immediately.

Mueller argues that a single-payer plan would actually cut costs, since up to 31 percent of current health care funds go toward administrative expenses. A Medicare-for-all plan would bring that number down dramatically, saving up to $200 billion. According to Mueller, that’s much more than enough to insure all currently uninsured individuals.

Moreover, if everyone received free basic maintenance care, fewer people would end up needing expensive treatment, and emergency rooms would not be overloaded with heart attack and stroke victims, according to Mueller.

“As an internist, you see the uninsured coming in really sick, all the time,” Mueller said. “You just shake your head in disgust, because you know you could’ve prevented it.”

The Risk Factor

No matter how many health professionals push for single-payer care, as a presidential candidate, the position is a major political risk, according to Davenport. Polls show that the majority of Americans think the government should guarantee health care for all, but not many trust the government to provide that care itself.

Part of it, according to Davenport, is simply a fear of change.

“People are afraid that with a big change, they’ll lose what little they have,” she said. “There’s a lot of anxiety about that. The leading candidates are really trying to pitch to what will get majority support.”

Along with that fear comes a lack of precedent for full-on government-funded care, according to Blendon. That element of newness, he says, is exacerbated by the current mood of uncertainty and distrust of the federal government’s efforts.
    “We have a system that historically has been based privately,” Blendon said. “In a period of such cynicism, that transition would be hard.”

The front-running candidates, he says, pick up on that sentiment; they aim to reform the current system, not create a new one. Obama and Clinton especially reinforce the sense that market-based health care is the American way, with Obama emphasizing “increasing competition” as a main peg of his plan, and Clinton stating that her proposal “puts consumers in the driver’s seat.”

Letting consumers drive means keeping insurance companies on board to fuel their tanks – and that’s a plus for financing a presidential campaign, McCanne notes. The leading Democratic candidates’ health care plans would provide subsidies for individuals to purchase private health care plans, working to the advantage of the corporations.

Clinton and Obama are the 2008 election cycle’s top recipients of pharmaceutical company money, while both rank close to the top of the list for insurance company money.

The candidates’ health care stances can’t be attributed automatically to campaign financing, according to Blendon: once they pick a position that would benefit the companies, they’ll garner contributions, whether or not they’re motivated by the prospect of those funds.

“If you pick a private sector approach, you’ll get support from the private sector,” he said. “It could be a byproduct of deciding not to go with the big government thing. If you talk about Medicare for all, you won’t get that kind of support. But I don’t know whether it was the chicken or the egg.”

However, for McCanne, the “which-came-first” dilemma is beside the point.

“They’re not going to be belligerent toward an industry that’s helping to elect them,” McCanne said. “It’s a clear-cut conflict of interest. Just the fact of a candidate accepting those funds is not good for the public good.”

Maya Schenwar is a Chicago-based freelance writer and an editor for Publications International.