Moving to the Center

Wharton health care management professor Mark Pauly notes major similarities in the two candidates' plans, particularly the emphasis on giving people choices among a wide variety of competing insurance plans. "That's a switch at least for the left wing of the Democratic party, which is more in love with a single-payer government plan," says Pauly. "On the Republican side, McCain has made a major concession by saying competition alone won't solve the problem, and we'll have to have substantial subsidies to help people afford insurance."

Pauly notes that the candidates also agree on some reform measures that will only amount to tweaks in the current system, such as health information technology, disease management programs, evidence-based medicine and the idea of a "Medical Home" in which a doctor or other health professional coordinates individual patient care to reduce excessive costs and improve outcomes. "All these things sound good and insurers ought to try them," says Pauly, "but there's not enough there yet to put it in the bank -- and these ideas are diverting attention from the structural issues."

The current debate, he notes, does not recognize that most of the uninsured in the United States are not sick or poor. "They are just taking a chance," says Pauly, who points out the motivation behind mandated health coverage in Massachusetts was to "prevent the grasshoppers of health insurance from being irresponsible." When tragedy befalls them they make for a sad vignette, but "You can't buy insurance in the ambulance on the way to the hospital and cancel it when you get out. It's worth noting that not everybody who fails to buy insurance is miserable."

Meanwhile, both candidates do very little to address rising costs in their plans and present overly optimistic views of how easy it will be to raise money to fund their initiatives, Pauly states. The main driver of health care spending is new technology that is beneficial to patients, but increasingly expensive. "The most serious fiscal problem is the result of a good thing. We live longer and better than before, but we haven't saved enough to finance it."

Wharton professor of health care management David Asch, who is also a professor of medicine at the University of Pennsylvania, says he is concerned about an over-emphasis on market forces and consumer-driven health care. McCain's plan to erode the role of employers in providing health care, by changing the tax structure, might be a major set-back in the process of health care reform, he suggests.

"Though it is not a perfect system, it is what we have right now, and I worry that getting rid of it in one fell swoop would be extremely dangerous," Asch says. He acknowledges that making consumers more responsible for health care spending might work to reduce costs and target medical resources more effectively. But the system is not yet equipped to give consumers the information about health care quality or pricing they would need to make the right decisions. "It's not like when you go into a store to buy a TV and you know what the TV will cost," he says. "Allowing patients to have skin in the game only works if they have the information [with] which a reasonable person could make a decision."

The faculty agreed that the future of health care will be based in economics and medical advances, but also politics.

According to Asch, the two candidates have more detailed plans for health care change than in earlier campaigns, but he warns that the plans are bound to alter dramatically as they work through the legislative process and into the economic and health care environment.

It is more important to pay attention to the basic partisan, ideological divides between the two candidates, he adds. McCain, the Republican, is more market-oriented, while Obama, the Democrat, is more inclined to provide government solutions. "Ideology is more important than any detail," says Asch, noting that neither candidate will have complete control over the shape of health care in the future. "The president isn't king and there's a political process that will change any plan that gets put forth before an election. No plan survives the battle."

Pauly recently served on a panel on which another speaker told him that politicians will never accept the need to curtail benefits "'unless they are literally against the wall.' Well, we're heading to the wall at 90 miles-per-hour. Wouldn't it be better to turn the wheel and experience a giant yank, rather than a head-on crash?" Pauly asks. "The system is melting down, but things may have to get worse before they get better because that's what it takes for political action."