Competing Prescriptions

With the March 4 primaries delivering finality on one side of the partisan divide and uncertainty on the other, it’s a good time to take stock of where the candidates are on health care. For now, most attention has centered on the scrap between Hillary Clinton and Barack Obama over an “individual mandate” requiring everyone to have health insurance. But this fight will look like a college seminar discussion compared with the take-no-prisoners battle that’s likely to emerge between John McCain and whomever the Democrats eventually nominate.

That’s because, when it comes to health care, Republicans are from Mars and Democrats from Venus. Republicans call for greater reliance on individually purchased insurance that requires people to pay a good chunk of the costs of care up front. Democrats call for expanding group health insurance that pools risks broadly and shields people from costs. A quick look at the health policy positions of the candidates makes this contrast abundantly clear -- and shows where the clash of competing prescriptions will soon head.

Let’s start with Senator McCain. Although he is on the moderate side of his party on health care, his signature proposal is extremely modest compared with what Senators Clinton and Obama are proposing, and very much in keeping with the new G.O.P. consensus.

Senator McCain wants to do two big things -- one admirable, one worrisome, but neither of which will greatly expand health insurance.

First, he wants to shift away from an open-ended tax break for health insurance toward a refundable tax credit. This would have the salutary effect of evening out the distribution of federal tax breaks for health insurance, which now greatly favor the well off. But Senator McCain wants to cap the tax credit at $2,500 for an individual and $5,000 for a family. Last year, the average premium for a family insurance policy was more than $12,000, according to the Kaiser Family Foundation, leaving a $7,000 gap for a family seeking to buy insurance with the new refundable credit. Not surprisingly, studies suggest that credits of the size proposed by Senator McCain will do little to help those without health insurance.

Second, John McCain wants to end the favoritism in the tax code toward employer-provided health insurance, which sounds good, except this favoritism has a motive: employer-provided health insurance is much more capable of pooling health risks than individually purchased private coverage. If healthier people are encouraged to opt out of employer-provided coverage to buy policies on their own, this could drive up costs for those left behind, and perhaps lead to the unraveling of workplace insurance.

That would be less of a concern if the Arizona senator had ideas for ensuring that people will be able to get guaranteed, affordable coverage, but so far he’s not been willing to embrace any serious insurance reforms, like requiring that health plans take all potential subscribers or that plans cover so-called preexisting conditions -- the health problems you want covered when you buy health insurance. Nor has he said how he will finance the new tax credits in light of his pledge to extend the Bush tax cuts.

Which brings us to Senators Clinton and Obama. I will say more about their plans and the fight between them in my next post. But for now, it’s worth emphasizing that their proposals are nearly carbon copies of each other. They include a requirement that all but the smallest employers either provide or contribute to the cost of health insurance; a new national insurance framework that would allow people to choose among private health plans, as well as gain access to a public insurance plan modeled after Medicare; substantial reform of the private insurance market to ensure that private plans don’t cherry-pick the healthy; and a new quality-improvement initiative spearheaded by the federal government. Both also want to spend a lot of new federal dollars -- about $60 billion when savings are taken into account -- and repeal the Bush tax cuts for upper-income taxpayers to come up with these dollars.

In short, the contrast could not be more stark. And it’s coming to a political theater near you: After sewing up the nomination on March 4, Senator McCain attacked the two Democratic candidates for embracing “the failed, big government mandates of the sixties and seventies to address problems such as the lack of health care insurance for some Americans,” and said he would cut costs and extend insurance without “ruining the quality of the world’s best medical care.” This is a preview of what’s to come: Republicans will savage Democratic plans as a threat to the quality and affordability of care for those who already have insurance.

But John McCain faces a serious risk if he pushes this attack too far. Americans are deeply concerned about health care, with polls showing near-record support for government action. And he will look badly out of touch if he keeps talking about American medical care as the “best in the world,” when so many Americans neither have access to it nor feel confident they can afford it.

Meanwhile, Senators Clinton and Obama have to stop fighting each other over the relatively small differences that divide them. Instead, during the primaries as well as afterward, the two candidates would help their own candidacies if they started talking about the positive changes their plans will bring about.

Indeed, when one takes the broader view, the two Democrats are battling each other on a gangplank over dangerous waters while Senator McCain is happily sharpening his saw for later this year.