WILL HEALTH CARE BE THE PRIMARY DOMESTIC ISSUE IN THE 2008 ELECTION?

Americans are aware of the paradox that, although the United States has the most sophisticated and innovative medical establishment in the world, more than one-quarter of all Americans derive very little benefit from it. At least forty-five million people in the United States have no health insurance and another forty million cannot count on enough coverage to provide for appropriate treatment in the event of a major disease or long-term care. President George W. Bush, with his curious form of compassionate conservatism, has pointed out that the emergency wards of hospitals are open to all. He has not pointed out that many emergency wards have closed because hospitals cannot afford them, that the cost of emergency treatment is far greater than timely and regular medical care, and that emergency treatment is often too late to be of value.

The present congressional consideration of health care for children has reminded the president that he is not only a compassionate conservative; he is also a fiscal conservative, despite the fact that, since taking office, he has turned a great surplus into the greatest indebtedness in American history, several times setting records for the biggest single yearly dollar increase in the debt. Nevertheless, despite the harsh criticism by former Federal Reserve Board Chairman Alan Greenspan, that Bush has betrayed conservatism, he plans to stem the tide of borrowing that has, on average, exceeded $500 billion a year by threatening to veto a children’s health insurance bill that would provide coverage for an additional four million children (beyond the 6.6 million already covered) at an additional cost of only $35 billion over five years. If Congress passes the bill and Bush vetoes it, health care for children will provide the centerpiece for what the Democrats will seek to make the defining domestic issue in the 2008 election.

On September 20, five leading Democrats – Joseph Biden, Hillary Clinton, Christopher Dodd, John Edwards, and Bill Richardson (Barack Obama was invited, but declined) – participated, with Judy Woodruff as moderator, in a wide-ranging ninety-minute discussion of health care. It was less confrontational than other public discussions in which the Democratic candidates have participated, but it was more informative because it was thoughtful and reasonably detailed. While there were a few not-so-subtle thrusts directed by one candidate at another, it was clear that all five believe in national health coverage, although they differ as to how it can be achieved.

Apparently, some doctors share that conviction. In 2004, in a physician-sponsored random sample of Massachusetts doctors, 63.5 percent of the 904 responding doctors believed a single-payer plan provided the best care for most people, 25.8 percent chose a fee-for-service system, and 10.7 percent selected managed care. Although many respondents doubted that most of their physician colleagues would support a single-payer system, most agreed that government has a responsibility to ensure the provision of medical care, it would be worth giving up some income to reduce paperwork, insurance firms should not play a major role in health care delivery, and they would prefer to work under a salary system. Of course, this may not reflect national preferences among doctors, but each of these changes could play an important role in a national health insurance system.

Earlier this year, John Edwards was the first Democrat to propose a detailed health care plan. One idea appears to have caught on with other Democratic aspirants. Edwards and his leading rivals agree that the American people should have the same health plan as members of Congress, which includes unlimited doctor visits, no deductibles and no co-payments, at a cost of $35 a month. Edwards has now gone further, promising legislation that would end the health insurance of the president and Congress in six months if they fail to adopt a comparable program for all Americans. Edwards would also minimize, if not eliminate, the role (and the profits) of insurance companies.

Barack Obama has also offered a detailed plan which would insure all children and require employers to share the costs of insuring workers, but would not mandate insurance for everyone. Hillary Clinton’s new plan would require it. Clinton would offer the equivalent of the congressional plan as one option, but she opposes the creation of a federal agency to achieve this objective. None of her rivals has taken Clinton to task for her commission’s 1994 recommendation to President Bill Clinton of a complex proposal that no one seemed to understand, except for its clear rejection of the single payer plan that had been favored in 1992-93 by many Democratic leaders in Congress.

The various plans sometimes differ or are unclear as to the extent to which individuals could buy coverage, employers would contribute, or the national government would underwrite the costs. When the Democratic candidates speculate as to the cost (often estimated at $100 billion or more), they tend to agree that a large part of this could be paid by repealing the income tax cuts on incomes above $200,000 enacted in the Bush presidency. Edwards would go further and increase the tax on investment income to the rate on earned income. Several candidates propose efficiencies in the health and tax systems that would serve to cut the cost of health care.

All of this stands in sharp contrast with the positions of the leading Republicans. Rudolph Giuliani predicts that the various Democratic plans would increase taxes and decrease the amount and quality of patient care (for example, increasing the waiting time to obtain an appointment). Giuliani advocates a $7500 tax deduction per taxpayer to defray insurance costs and tax credits for poor workers to supplement Medicaid and employer contributions. John McCain would go further than some of his Republican rivals, favoring prescription drug coverage for the elderly and expanded children’s coverage. Mitt Romney would offer incentives for the states to expand affordable coverage, condemning the Democratic proposals as “European-style socialized medicine.” The other Republican hopefuls (Fred Thompson, Sam Brownback, Mike Huckabee, Ron Paul, and Duncan Hunter) all voice variations of “market-based solutions” and “market-driven expansion” of affordable coverage to express their opposition to any government-run program, let alone guaranteed universal coverage.

Numerous statistics demonstrate that far less prosperous countries have far better health records. The United States ranks seventeenth in the percentage of one-year-old children who are fully immunized against polio. China and Brazil both rank ahead of the U.S. in this regard. Many countries, including Jordan and Egypt, have lower rates of low birth-rate babies than the U.S. Shockingly, but not surprisingly, these figures reflect the fact that, among industrialized nations, the United States has the highest percentage of children living below the poverty line.

The World Health Organization (WHO) of the United Nations has often pointed out that the United States ranks behind other industrial nations in what the WHO calls “healthy life expectancy.” All of these and other health statistics show a wide disparity along racial and ethnic lines, with blacks and Hispanics overrepresented among the least privileged populations. Dr. Ashish Jha of the Harvard School of Public Health has testified that surgeons are very much less likely to offer bypass surgery to black men than to white men who have had a heart attack similar to that suffered by President Bill Clinton.

“Socialized medicine” is a phrase that critics will employ and advocates will shun. Rational examination discloses that, by other names, socialization of public benefits have a place -- an honored place -- in American public policy. Free public education is the oldest example. More than seventy years ago, critics railed against adoption of the Social Security Act, which provides an assured old-age income to almost all older Americans. Medicare is Social Security’s logical extension, in that it extends health care beyond the recipient’s ability to pay. Scare tactics, such as condemnation of reform as “socialism” without a rational analysis of what particular reforms do or fail to do, will not dispose of the challenge, not if the American people believe, as evidence increasingly indicates they do believe, that the government has a role to play in the protection of health and the provision of essential health services.

The candidates are obliged to answer these questions. Where does universal health coverage exist and how well does it work? Does the quality of health care and its cost decline or improve under a government-mandated health care program? Is it compatible with private medical insurance? Does it require the regulation of pharmaceutical companies and drug prices? What is most remarkable is that this debate in the United States will take place, if it takes place, decades after it was resolved in other industrial countries. And that also raises the question as to why the richest country in the world, with its unparalleled medical research and resources, has come so late to this issue.

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WEDNESDAY, SEPTEMBER 19, 3007

POSTSCRIPT to September 15:
Does the President or the General decide whether and how to wage war?

MoveOn's sharp criticism of General Petraeus (calling him General Betray Us) is a stupid tactic and a completely false assessment of moral and military responsibility. This clumsy personal attack permits defenders of the Iraq war to deflect criticism of its conception and conduct and focus on a misguided attempt at character assassination. General Petraeus is neither the savior President Bush has represented him as being nor is he the subversive officer MoveOn has portrayed. He is simply the general President Bush has settled on to be the spokesman for his failed policies. The war is Bush's war. The false rationale for invading Iraq was accepted by President Bush. The grievous errors committed in the conduct of the war were the responsibility of the Commander-in-Chief, President Bush, who had the power to reverse errors. He did not. The loss of American prestige and good-will throughout the world is the consequence of policies pursued by President Bush. The absence of an exit strategy results from an inability to assess alternatives or face reality by President Bush.

Similarly, any charge that lays responsibility for America's greatest foreign policy failure upon Vice President Cheney or former Defense Secretary Rumsfeld or the proselytizers for American hegemony ignores the fundamental fact that none of the grievous errors could have taken place without the action of President Bush. It is even more inexcusable to blame the general who was eager or willing to carry out the president's orders. What President Truman reminded himself of in the Oval Office has not changed. The buck stops there.