The healthcare plans of presidential hopefuls Barack Obama and John McCain share few similarities, but either way, physicians can count on increased scrutiny of their clinical choices no matter who wins the election.

by Emily P. Walker, Washington Correspondent, MedPage Today

DENVER, Aug. 25 — Physicians can count on increased scrutiny of their clinical choices no matter who wins the election, said a prominent healthcare economist.

While the healthcare plans of presidential hopefuls Barack Obama and John McCain share few similarities, “at some point, both candidates would probably push to put physicians into a statistical fishbowl,” according to Uwe Reinhardt, Ph.D., of Princeton.

Both plans promise to increase the number of people with health insurance, which will mainline money into the medical system. As more people and money are brought into the healthcare system, increased accountability of how that money is spent is a certainty, said Dr. Reinhardt.

On his Web site, McCain said his plan would require transparency about medical outcomes, quality of care, costs and prices. He said a national standard for measuring outcomes must be created.

Obama’s plan would require doctors and hospitals to collect and report cost and quality measures, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and care disparities.

Action Points
Explain that the healthcare plans of Barack Obama and John McCain would both cause physicians to have to be more accountable to payers for clinical choices, according to a healthcare economist.

“The average American doctor still practices behind a veil of complete secrecy,” Dr. Reinhardt said. “Within the next five years, more and more doctors will find that veil of secrecy pulled back. Their outcomes will be known.”

If that increased openness raises liability concerns, consider that Obama’s plan would bolster laws to prevent insurers from overcharging physicians for malpractice insurance. McCain’s calls for liability reform are aimed at eliminating suits against doctors who followed clinical guidelines and adhered to safety standards.

Robert Doherty, senior vice president for governmental affairs for the American College of Physicians, said he is concerned that the primary care workforce is ill equipped to handle a huge infusion of patients into the healthcare system. He said that countries with a robust primary care workforce tend to be healthier and have lower healthcare costs.

Doherty said while neither plan goes far enough to bolster the primary care workforce, Obama’s promises loan forgiveness for students who choose to go into primary care.

What the candidates agree on is that the annual $2 trillion price tag for healthcare in the United States is dramatically high and needs to be reduced, while expanding coverage to the 47 million uninsured Americans. McCain and Obama have quite different ideas on how to achieve those seemingly contradictory goals.

“The candidate’s opposing visions of healthcare reform reflect fundamentally different assumptions about the virtues and vices of markets and government,” said Jonathan Oberlander, Ph.D., of the University of North Carolina at Chapel Hill, in a New England Journal of Medicine perspective.

Obama’s plan would create a taxpayer-funded national health insurance program that would be similar to the plan available to members of Congress. People who don’t qualify for Medicare or Medicaid but still need financial help would receive an income-related subsidy to either buy into the national plan, or to go toward the purchase of a private plan.

“It would essentially be a private market solution with the exception that he adds a government program for Americans who are comfortable with that,” Dr. Reinhardt said.

For those wishing to keep or buy a private plan, Obama’s plan would create the National Health Insurance Exchange, a watchdog group that would make sure private insurers offer plans at least as generous and comprehensive as those offered under the national plan. Obama’s plan would make it illegal for insurers to deny coverage based on a pre-existing condition.

Obama also said he would expand Medicaid to cover a wider swath of people and expand SCHIP eligibility for children.

McCain’s plan would not create any new insurance programs. Rather, it would aim to infuse the current insurance market with a larger number of people who can afford coverage by offering tax credits of $2,500 for individuals and $5,000 for families to go toward the purchase of an insurance plan.

He has said the rebates will be budget-neutral, because the money would come from raising income taxes for employees geared to the amount their employer spends on their healthcare.

Dr. Reinhardt said the intention is that the rebates would compensate for the increase, but said he has not seen any numbers on whether the rebates would offset — or more than offset — the increased income tax.

He added that in order to give people cash to spend on healthcare, Congress would have to first approve raising income taxes for people whose employers pay for their healthcare — an unlikely feat no matter which party controls Congress.

Under McCain’s plan, patients can keep the same coverage even if they switch jobs. Obama’s national program would allow for portability.

While both plans are aimed at expanding coverage, the candidates stay away from a term that proved to be a political deathblow for Hillary Clinton’s healthcare reform plan in the 1990s: “universal mandates.”

McCain’s plan does not require that any group must have insurance. Obama’s plan would require that all children are insured, but doesn’t apply the requirement to adults. It does however, require that employers provide coverage for all employees, and pledges $6 billion to go toward helping small business pay for covering employees with particularly high healthcare costs.

Dr. Reinhardt predicts that a bill to mandate coverage for all children would win easy passage in Congress, since either party would be loathe to vote against providing “kiddie-coverage.”

Harvard economist David Cutler, Ph.D., an adviser for Obama, told MedPage Today that individual mandates are an option in the future as part of Obama’s pan, but he said the reforms need time to work before all Americans should be required to buy in. The Obama camp calls this “sequencing,” but Reinhardt and Doherty both said it is more of a political move than a substantive pledge.

“Neither candidate goes far enough to guarantee coverage,” Doherty said. “We’d like to see some mandate.”

Under McCain’s plan, employees who receive healthcare benefits from their employers, as most Americans do, would be taxed on the care their employers purchase for them. Those who make more money would be taxed in a higher bracket. The government would then give tax credits — $2,500 for an individual and $5,000 for a family — to purchase care from whichever provider they chose.

Doherty said that coverage for a family of four averages about $12,000 annually, and said that subsidies in any plan must keep pace with inflation and rising costs.

Both plans look to familiar places to save money, such as preventive care, and modernizing the healthcare system with technological advances such as computerized prescriptions and medical records.

In a 2007 memorandum written by Dr. Culter and two other economists and Obama advisers, the advisers predicted computerized medical records would save $77 billion a year, and said that bolstering prevention programs and focusing on chronic disease management would add up to $81 billion in savings.

But a report by the Congressional Budget Office in May said the cost-savings hype around health information technology may be overblown.

“By itself, the adoption of more health information technology is generally not sufficient to produce significant cost savings,” the report said.

Dr. Reinhardt also does not agree that improving technology and prevention actually save money, although such changes would certainly benefit patients, he said.

Dr. Oberlander agreed that cost-saving produced would be minimal.

“Prevention, better care for chronic conditions are enhanced aspirations rather than concrete policies for controlling costs,” said Dr. Oberlander, in his NEJM article.

Dr. Reinhardt is not optimistic about either candidate following through on his healthcare promise, especially in light of new polls that show the public’s waning interest in healthcare reform.

Doherty said change is more likely under Obama.

“The prospects of reform getting enacted with McCain is less likely because you will have a divided Congress,” Doherty said. But even with Obama, it’s no slam dunk, he said.

McCain has said his plan will be budget neutral, and his advisors have declined to comment on the predicted savings. Obama’s advisers said his plan will cost about $50 billion to $65 billion per year, partly offset by rolling back the Bush tax cuts, and save $214 billion annually.

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Published: August 25, 2008

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