Clinton vs. Obama on Health Care
Democratic Debate in Las Vegas, November 15, 2007
"His plan would leave 15 million Americans out...I have a universal health care plan that covers everyone."
"The fact of the matter is that I do provide universal health care."
They can't both be right--or can they? The health care plans proposed by Senators Clinton and Obama are similar in many ways, but they differ in several important respects. The Clinton plan "mandates" health insurance for everyone. The Obama plan requires that all children have insurance, and subsidizes health care for other Americans who are presently uninsured. Clinton estimates that her plan will cost in the region of $110 billion a year; Obama has put a $50 to $65 billion price tag on his proposals.
The truth is that neither the Obama plan, nor the Clinton plan, guarantees "universal coverage" for all Americans, although they both aspire to this goal. Let's look at the Clinton plan first.
MIT economics professor Jonathan Gruber, one of Clinton's health care advisers, describes her plan as a "universal coverage" plan, in contrast to the Obama plan, which he terms a "universal access" plan. But he also acknowledges that the Clinton plan will not include everybody. "Any system that does not have a single payer will not have 100 per cent coverage," he told me, when I reached him after the Las Vegas debate. "But you can come very close."
By "single payer," Gruber means a national health insurance system along the lines of Britain or Canada, which do provide universal coverage. The system proposed by Clinton is more analagous to the government-subsidized private insurance system in the Netherlands, where roughly one and a half per cent of the population is estimated to fall through the cracks.
The Clinton plan is also comparable to the health care plan introduced in Massachusetts by Governor Mitt Romney (who is opposed to extending the experiment to the rest of the United States.) It provides various incentives and penalties for uninsured residents of Massachusetts to subscribe to a health plan. Known as "The Connector," the Massachusetts plan has so so far enrolled 200,000 out of 400,000 uninsured residents. The big unknown is how many of the remainder will sign up once health insurance becomes "mandatory" at the end of this year. Some Massachussets residents have already been exempted from the "mandatory" health insurance requirement.
"The only place in the U.S. that has attempted a mandate is Massachusetts, and we do not know if it is going to work here," said David Blumenthal, a professor of health policy at Harvard university and an adviser to the Obama campaign. "A mandate is not a slam-dunk solution. The key question is whether there is the political will to enforce the mandate once it goes into effect."
Blumenthal concedes that the Obama plan will not cover all the uninsured, at least to begin with. But he claims that Obama will do a better job than Clinton in reducing the cost of health care premiums. He says that Obama might consider a mandate at a later stage, if his present plan does not achieve its goal of universal coverage.
So where did Clinton get her figure of 15 million uninsured under the Obama plan? Her website cites an article in the New Republic, hardly an authoritative source. On the other hand, it is more than just a wild guess. The Urban Institute, a Washington-based think tank, gamed out various different models for health care reform in Massachusetts several years ago. According to John Holohan, one of the authors of the study, "we estimated that we would probably get half the uninsured without a mandate." Extrapolated to the whole country, that would leave 22 million out of 45 million people still uninsured. Since the Obama plan provides for mandatory insurance for children, the total number of uninsured would probably come down to around 15 million.
Like the other experts, Holohan does not believe that either the Clinton or the Obama plan will eliminate the problem of the uninsured altogether. "We would all be very happy if we got down to one and a half per cent," he said.
The Pinocchio Test
Neither Clinton nor Obama are being fully candid about the gaps in their health care proposals. Neither plan truly provides for "universal" coverage, although Clinton's proposal probably comes somewhat closer to reaching this goal than Obama's. There are strengths, drawbacks, and loopholes to both plans. At this point, nobody knows how many uninsured they will include, but it will not 100 per cent. Much will depend on their ability to work with Congress once they are elected. If they were being honest with the voters, they would say that universal health care coverage is an aspiration, not a guarantee. Two Pinocchios apiece.