Nelb: McCain’s health care: Rhetoric, not reality

For any astute policy analyst, convention-watching can be particularly painful. Buzzwords replace real issues and the truth depends on who’s talking. Perhaps this is just politics as usual, but the lack of reality in today’s rhetoric is a disturbing trend that concerns us all.

In Denver, Barack Obama at least tried to describe what he means by “change,” but in Minneapolis, John McCain embraced platitudes and politicking with open arms. I was shocked by McCain’s blatant misrepresentations of Obama’s positions on taxes and energy, but as a student of health policy, it was his two sentences about health reform that really made me cringe.

McCain began by describing his plan as one that makes it “easier for more Americans to find and keep good health care insurance.” When one looks into the details of the McCain health-care plan, however, the reality is anything but easy. The central tenet of McCain’s health plan is the elimination of federal subsidies for employer-sponsored health insurance, on which 160 million Americans currently rely to get their health-insurance coverage. In its place, McCain’s plan gives families tax subsidies to encourage them to buy insurance on their own without much help from the government. Placing a larger burden on individuals may reduce government spending on healthcare, but it won’t make the process any easier. According to a recent Kaiser Family Foundation poll, as many as four out of five Americans feel that buying individual health insurance would be more difficult than getting it from their employer.

Meanwhile, McCain characterized Obama’s health policy plan as one that will “force small businesses to cut jobs, reduce wages and force families into a government-run health-care system where a bureaucrat stands between you and your doctor.” This may sound a lot like the Republican attacks in 1994, but Bill Clinton and Barack Obama’s health plans are anything but the same. Unlike the ’94 Clinton plan, Obama’s proposal has as its first principle that you can keep the plan you have if you want — no one is forced to do anything. Rather than implement a government-run system for all, Obama takes an incremental approach, expanding existing programs and allowing families to access to the Federal Employees Health Benefit Plan, a menu of private health-insurance options with a comprehensive set of benefits that members of Congress currently enjoy. In short, Obama’s plan isn’t some foreign form of socialized medicine; it is an incremental solution that builds on what already works well in America.

Overall, McCain’s statement was so badly twisted that it may be more accurate if it were reversed: Obama’s plan would make it easier for more Americans to find and keep good health insurance (since it allows people to keep the care that they have), while McCain’s will likely cause many businesses to drop health-insurance coverage and will force families to deal with HMO bureaucrats as they fend for themselves in the private health-insurance market (since it cuts subsidies for employer-sponsored health insurance and doesn’t fully fix the individual health insurance market).

Perhaps I am too idealistic, but should we not hold our leaders accountable when they lie to us like this? Instead, the polls suggest McCain is benefiting from his misrepresentations. McCain has somehow become a candidate of change as well, and skinning a grizzly bear has suddenly become a more important qualification than graduating magna cum laude from Harvard Law. It’s OK if someone wants to vote for McCain because of his policies or his record, but please don’t vote for a four-term Senator because you think that he can bring a fresh face to Washington.

Now that I’m back at Yale, it is tempting to become cynical about politics, but in this upcoming election, the stakes are too high to stay silent. I look forward to writing this column for its third year to do my part to promote informed debate about public-health issues in New Haven and around the world. Together, we can bring a dose of reality to today’s rhetoric and make the world a healthier place.

Robert Nelb is a student at the School of Public Health.


  • Yale 08

    Health Care is beyond the scope of government.

    The first candidate to understand this gets my vote.

  • Kevin

    Obama's plan would give uninsured people access to government funded insurance? Who would pay for this? Obviously the taxpayers. Government was never meant to pay for healthcare. Government should stick to the basics: defense and infrastructure and leave everything else to private sector. Go McCain-Palin!

  • Anonymous

    Right, because the government's been doing a bang-up job on defense and infrastructure lately. The taxpayers could cover every man, woman and child in America for a fraction of our annual (hell, barely our MONTHLY) budget in Iraq. Ditto bridge and levee repairs.

  • Barb

    YIKES! Government health insurance is a lot of coverage for almost no money out of pocket. If Obama is only raising taxes for 5% of Americans, I feel sorry for those of us in that 5% who are footing the bill.

  • Yale 08

    If you take away the pricing of risk from health care coverage, you create a MASSIVE moral hazard.

    People will gorge themselves on health care.

    There's no such thing as a free lunch…

  • Yale 08


    Yes, the government could do many things, but at what cost?

    And what gives the government the right to do such things?

    The government had its shot at healthcare: see the VA hospitals- declining, horrid places with poor quality and long waits.

    Give the government control of a good or service and you will only see a few options:

    high costs via higher taxes

    low quality due to the inability to dicriminate in any fashion, even via prices

    long lines, short supply, endless waits due to rationing

  • ConspicuousConsumption

    Yale08, I can see the lines stretching down the Cedar Street ER entrance already because emergency rooms are just *Such Fun Places to Be* (TM)! Your moral hazard argument assumes that people will seek absurd amounts of unneeded care because there are no cost pressures. But no one has claimed that there won't be cost-sharing mechanisms in a public insurance option (see Medicare). There will still be "skin in the game" under Obama's plan.

    Also, let's get real. If your beef with Obama's plan is that previously uninsured individuals will have coverage and see doctors when they're sick, I think you're missing the point. In medicine, the goal is to make people healthier and give them better lives as a result. The idea behind public insurance option in the Exchange is to make it feasible for all Americans to have health coverage. Here, the focus is on the 45+ million Americans who don't have insurance, and they're the ones who don't even have a PCP. The cost of one routine checkup is a fraction the cost of one inpatient day. I personally would be fine with a patient's preventing an acute episode because (1) it may save money and (2) more importantly, the person will be healthier.

    Finally, please don't pretend that you're arguing in the best interests of currently uninsured people because of your dystopic vision of "long lines" and "poor quality." First, prove your claims. Second, uninsured Americans aren't seeing physicians when they need to; they go to the ER when diseases have progressed; and they actually die earlier (see the IOM). If you're afraid of "rationing," here's a news flash: we already ration. If you don't have insurance, you don't get care unless you bankrupt yourself.

  • Yale 08

    Eliminate the tax credit for employer provided health care.

    Then individuals/families purchase catastrophic health care insurance (for cancer, AIDS, transplants, etc)- this would be relatively long tail and thus cheap- like term life insurance.

    Individuals/Families then retain the risk/costs of preventative/routine helath care- checkups, over the counter meds, visions, dental, etc. They can place funds in a tax sheltered health care savings account for these costs. Any unused funds in one year can be simply saved for next year.

    This has several advantages:

    Removes employers from the healthcare business.

    Turns health insurance from a limitless grab-bag of funds into an actual risk management device.

    Allows individuals and families to make their OWN choices regarding attitudes and appetites for certain levels of care.

    Creates incentives for health care consumers to seek the best combination of quality and pricing from health care providers. The important piece of this is that the CONSUMERS decide what matters to them- not the health care companies, not the doctors, and for God's sake not the government!

    The price/quality differentiation and competition between doctors and hospitals will ensure that every segment of the healthcare market will be serviced- from the poorest of the poor, to the wealthiest.

    Look at what this competition has done for "elective" medicine: LASIK and cosmetic surgery- quality has increased while prices have plummeted.

    Let the market solve healthcare.

    Let there be a Walmart of hospitals!!!

  • Steve

    This is one way to eliminate the uninsured. Just redefine them according to a McCain advisor. From the Dallas Morning News.

    But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

    "So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

    "So, there you have it. Voila! Problem solved."

  • Yale 08

    To Steve:

    It's true, it really is.

    The government "insures" many people/property.

    State pools provide insurance-like coverage for those in the non-standard automobile market (ie those w/ so many crashes that they would get charged a high price in the free insurance market)

    State funds provide markets of last resort for workers comp insurance.

    Federal flood insurance is available to those on the coast/waterways.

    The gov't has recently provided a type of credit default insurance on Fannie Mae and Freddie Mac.

    The gov't does insure people thru Medicare/Medicaid and by mandating ER service availability.

    The problem with all of this is not the coverage- but the relationship between COST, RISK, and PROFIT/LOSS.

    The government simply assumes the entirety of the bill, or charges for the services NOT according to the actual underwriting risk, but according to what the legislature or insurance commission deems "fair".

    This is not freedom, nor choice.

    Once the gov't pays your bills- the gov't makes the decisions.

    This is not free- the massive costs are dumped onto the next generation.

    Allowing the market to underwrite risks will allow for the best efficiency of quality, and pricing.

    Private charity will rush to rescue the poorest of the poor, while the market-led reforms/innovations/advances in healthcare will ensure that the "rising tide lifts all boats."

  • ConspicuousConsumption

    Yale 08, have you’ve been reading too many campaign websites. Thanks for your textbook definitions of HSAs and rollover… Unfortunately, your soundbytes lack substance. After you eliminate the tax credit for employer care, you have to ensure that there are viable alternatives for families who lose their employer coverage and for people who never had coverage in the first place. So far, McCain (who supports decoupling now) hasn’t proposed any solutions for this problem. But we’ll get to that again in a second.
    First, catastrophic health insurance or high-deductible plans discourage *necessary* and *appropriate* health care consumption. If you read the latest literature, high-deductibles actually prevent people from seeking preventive care and care for chronic illnesses; these effects are disproportionately borne by poor Americans. As someone who’s so interested in economics, I’ll assume that you understand that emergency care for acute conditions is not cost-effective; it’s not ethical, either.
    Second, all of your talk about “choice” and “taking control” means nothing to uninsured Americans. You’ve failed to address the fact that your promotion of the individual health insurance market does *nothing* to cover the 45 million uninsured Americans. People who don’t have any insurance aren’t worried about LASIK (talk about “out of touch”). Why don’t you start thinking about people who can’t afford their diabetes treatment and thus have to get an amputation because of complications? Why don’t you think about the resulting disability, the impaired ability to work, and the toll that such an injury would take on a family?
    Price differentiation in itself has never guaranteed *quality* service to everyone. Also, by advocating quality differentiation and price segmentation, you’ve just proposed that poorer Americans *should* get lower-quality service. Unfortunately, for health care, lower-quality service leads to premature disability and death. No current presidential candidate believes in this type of hokey. My suggestion to you: Stop thinking about how beautifully LASIK prices have lowered due to competition and start thinking about the moral implications of your advocacy.