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The United States is the only wealthy, developed nation that does not provide guaranteed health care for all of its citizens, regardless of their ability to pay. According to Families USA, a nonprofit and nonpartisan health organization, nearly 90 million Americans (almost a third of the country) went without health care for all or part of 2006-2007. Because the uninsured are less likely to get routine preventive care, they are more likely to wind up sick. That's a problem for all of us because sick people are less productive than healthy ones, and when the uninsured can't afford to pay their medical bills, health premiums go up, passing extra costs on to everyone else.
In spite of the large number of uninsured Americans, the United States spends more than $2.1 trillion each year on health care. That's more than any other nation and is expected to double by 2017. Considering how much money we spend on health care, one would expect the United States to be one of the healthiest nations in the world. But we're not. We're one of the sickest. Our rates of chronic (and often preventable) conditions like obesity, diabetes, hypertension and heart disease are on the rise, while life expectancies are on the decline. In fact, babies being born right now in 41 other countries can expect to outlive a baby born today in the United States.
This is largely because of the United States' growing gap between the rich and the poor -- how healthy a person is depends just as much on socioeconomic status as on access to health services -- but it also reflects the failed policies of politicians who view health as a personal responsibility, when arguably, it should be a right. And therein lies one of the most fundamental differences between the presidential candidates' approaches to health reform: Obama has stated health care should a right; McCain has stated it should be a responsibility. That distinction guides how they plan to address everything from Medicare reform to the obesity epidemic. To further break down those differences, we've compiled a voter guide on this year's most important health issues. Keep reading to see how the candidates compare.
1. QUALITY HEALTH CARE FOR ALL
The United States has a health crisis on its hands. Quality health care is increasingly out of reach for cash-strapped Americans whose stagnant wages can't keep up with the rising costs of health insurance. Close to 16 percent of Americans -- 48 million -- are uninsured; the number of Americans with employer-paid health insurance is in steady decline; and half of bankruptcy filers in the United States last year said medical causes were to blame. Besides being unaffordable, many health insurance policies are also discriminatory -- they refuse patients with pre-existing or chronic conditions -- and don't offer comprehensive benefits. In short, our profit-driven, privately funded health system has resulted in high-cost, low-quality, inefficient care.
- Solution: Adopt a publicly funded, universal, single-payer health care system that would guarantee quality coverage for all Americans. Coverage should include a full range of medical services -- e.g. mental health, maternity and preventive care -- similar to what members of Congress now enjoy. Unlike patchwork approaches to providing universal health care, a single-payer system not only makes sense from a human rights perspective, it's arguably the smartest choice financially. A full 60 percent of the U.S. health care system is already publicly funded through local, state and federal taxes. Taking the next step and eliminating private spending would cut waste and save money -- Public Citizen estimates it could save $286 billion in administrative costs alone.
- Obama's position: Obama has described health care as a right. His plan would create a new framework for health coverage called the National Health Insurance Exchange (NHIE), which is a public plan that would give individuals who don't already have access to care through Medicaid, the State Children's Health Insurance Program (SCHIP) or employer insurance a guaranteed way to get coverage (with full benefits), regardless of pre-existing conditions. Obama would require employers to enroll their workers in a health plan, but workers could choose to opt out. Obama's proposal is not single-payer and would not provide truly universal coverage, but it would reach nearly all children and more than half of those currently uninsured, reducing the total number of uninsured, non-elderly individuals from 17 percent to 6 percent. Read Obama's full plan. Read a nonpartisan analysis of Obama's plan.
- McCain's position: John McCain would almost completely change the way Americans currently obtain health coverage, keep the number of uninsured individuals about the same and make it more difficult and less affordable for people with health problems to get coverage. Here's how it would work: McCain would use an approximately $3.6 trillion tax on workers over the next 10 years, take revenue from that tax, turn around and give it back to you as a credit ($5,000 for families; $2,500 for individuals) so you can buy coverage on the open market. This approach would replace the current income tax exclusion that allows Americans (about 140 million of us) to get health care from our jobs, tax-free. McCain's plan would create a disincentive for employers to continue buying coverage, and as many as 20 million Americans could lose their employer-paid coverage under a McCain presidency. Even though those people could use their tax credits to purchase insurance themselves, there's a good chance they would remain underinsured because individuals do not have the power that employers do to negotiate good rates from insurance companies. And $5,000 is too low to cover a typical family premium on the open market, which is closer to $12,000. Read a nonpartisan analysis of McCain's health care plan.
- Learn more: Health Beat, Families USA, OurFuture.org, Urban Institute Health Policy Center
2. OBESITY
Obesity, a major contributor to an array of health problems including heart disease, Type 2 diabetes, sleep apnea and even cancer, is one of the leading preventable causes of death. Yet, according to the Centers for Disease Control and Prevention, obesity has risen dramatically in the United States over the past 20 years, with 20 percent or more of adults being obese in every state except Colorado, which is closer to 15 percent. Thirty states have an obesity prevalence of at least 25 percent, or 1 in 4, and three states have a prevalence of 30 percent or greater. The obesity epidemic is also troubling among children, who often carry the extra weight with them into adulthood. The CDC estimates 15 percent of children and adolescents in the United States are obese. Some of the biggest factors contributing to obesity are sedentary lifestyles, calorie-rich but nutritionally deficient diets, poverty and a deregulated but highly competitive food industry that encourages overeating (especially of highly processed foods).
- Solution: Food marketing and advertising to children should be federally regulated. The food industry should have stricter labeling regulations for processed and/or imitation foods. Schools need healthier menus and more funding for physical education. Communities should be designed in ways that promote physical activity and offer safe locations for children to play.
- Obama's position: Obama has not presented a formal plan for combating obesity, but he has spoken of the need for more federal funding for physical education, an increase in preventative health care, healthier school menus and healthier community designs. In 2005, Obama introduced the Healthy Communities Act to promote active lifestyles: "With some exceptions, we are just starting to design communities with active living in mind," Obama said. "We need playgrounds so our children can be active; we need bike and walking paths that are safe and accessible. Schools and work places that are within walking distance of homes should be the norm, not the exception. We as a society are moving in that direction, and we need public policy that supports these efforts and ensures that all segments of society reap the rewards of healthy living." Regarding junk food marketing to children, the Obama campaign has said the food industry should be self-regulatory. If that is not successful, Obama said voluntary guidelines should become mandatory, and the Federal Trade Commission should "enforce compliance."
- McCain's position: McCain has said the food industry should be largely self-regulatory. He told Washington Post reporters that he "encourages food manufacturers and marketers to create voluntary standards to regulate advertising and marketing toward children as necessary."
- Learn more: National Action Against Obesity, The Obesity Society, What to Eat
3. INFORMATION TECHNOLOGY
Most medical records are kept on paper. This makes storing, tracking and accessing those records costly and time-consuming for providers and patients. This wasteful process is not only frustrating; it can be dangerous and lead to medical errors. According to the
New England Journal of Medicine, nearly a quarter of health care costs are administrative. Digitizing medical records could dramatically lower those costs and increase the quality of patient care. A Rand Corporation study found that adopting electronic health records could save up to
$162 billion a year.
- Solution: Develop and implement an electronic health information system and digitize all medical records.
- Obama's position: According to Obama's campaign, he and Joe Biden will invest $10 billion a year over the next five years in electronic information technology systems in the health sector. Obama also says he will ensure that patient privacy is protected.
- McCain's position: McCain's position is less clear, and he does not appear to have a formal plan. His Web site states, "We should promote the rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines." Since state licensure determines where a physician can practice, it is unclear why the McCain campaign has linked information technology to state lines. Note also that McCain says we "should" promote new tech systems. Unlike Obama, he does not say he "will" make sure that happens.
- Learn more: The Health Care Blog, Health Affairs, RAND Corporation
4. MEDICAID
Medicaid, a program designed to meet the health care needs of low-income and disabled individuals, offers comprehensive coverage including nursing home care and excellent prescription drug benefits. But, since Medicaid requires lots of paperwork and reimburses doctors at rates that are often much lower than Medicare or private insurance, many physicians are closing their doors to lower-income patients. This comes at a time when the number of Medicaid enrollees is growing. And because poor people tend to be in poorer health, that means some of the nation's neediest citizens are going without care. This was the case with Deamonte Driver, the young boy from Maryland who last year complained of a toothache and died after being unable to find a dentist to help him.
- Solution: Expand Medicaid and reform its payment system. One strong reform possibility would be folding Medicaid (and SCHIP) into Medicare, which would increase patient coverage and physician reimbursement.
- Obama's position: Obama's health care plan would expand eligibility for Medicaid and create a new public health insurance program that would cover citizens not eligible for health care under Medicaid or under an employer plan. Obama has not provided details on the new eligibility requirements and has offered no known specifics on Medicaid reimbursement.
- McCain's position: John McCain says he will make $1.3 trillion in cuts to Medicaid and Medicare over the next 10 years to help pay the costs of his health care reform plan. He has not specified where those cuts would come from.
- Learn more: Health Beat, Health Policy Watch, Urban Institute Health Policy Center
5. MEDICARE
Medicare is running out of money. Four years ago, its trust fund that covers inpatient hospital care started bringing in less money than it pays out. Medicare does not take a treatment's effectiveness into consideration before doling out money, leading to overpayments to drug companies, medical device manufacturers, physicians, hospitals and private insurers who offer
Medicare Advantage. (It is important to note that unlike Medicaid, which is a needs-based program jointly funded by the federal government and the states, Medicare is a social insurance program, designed to provide federally controlled, uniformly applied health care to seniors across the country.)
- Solution: Reform Medicare by eliminating large bonuses to Medicare Advantage insurers; repeal the part of Medicare that keeps the federal government from negotiating with drug companies; make payments based not just on quantity of care but on quality; and develop an independent institute that would "compare new, cutting-edge drugs, devices and procedures to the less expensive products and treatments that they are trying to replace." This would help put an end to "one-size-fits-all" medicine.
- Obama's position: Obama's plan would eliminate windfall subsidies to Medicare Advantage insurers, lift the ban that prevents the federal government from negotiating with drug companies and establish an independent institute to improve health care quality and stop the one-size-fits-all approach to medicine.
- McCain's position: John McCain says he will make $1.3 trillion in cuts to Medicaid and Medicare over the next 10 years to help pay the costs of his health care reform plan. He has not specified where those cuts would come from. McCain has also proposed to make wealthier Medicare recipients pay more for their drug benefits (Part D), a step toward the privatization and, many health care advocates say, the eventual demise of Medicare. If prices increase for higher-income individuals, they could feasibly opt out of Medicare, making it more of a welfare program than a social contract.
- Learn more: Health Beat, Health Policy Watch, Urban Institute Health Policy Center
6. PRESCRIPTION DRUGS
Prescriptions are becoming increasingly unaffordable for Americans, with the average price of drugs more than doubling in the last decade. At the same time, according to the
Census Bureau, prescriptions written in the United States have increased 61 percent, and the FDA has fast-tracked a growing number of drugs to market, in spite of serious safety concerns.
- Solution: Increase the entry of safe, low-cost generic drugs to the market and buy safe prescription drugs from other countries to drive drug costs down. Lift the ban that keeps the federal government from negotiating with drug companies to get better prices for Medicare. Close the "doughnut hole" in Medicare's prescription drug plan (Part D), which forces beneficiaries to pay all drug costs after an initial spending limit until a second, higher amount is reached.
- Obama's position: Obama has proposed increasing the use of generic drugs, purchasing drugs from other countries, allowing the federal government to negotiate with drug companies on Medicare's behalf (as it does for veterans) and closing the doughnut hole in Medicare's Part D.
- McCain's position: McCain has proposed the faster introduction of generic drugs to the market and the purchasing of drugs from Canada and other countries. McCain voted against the initial proposal of Medicare's prescription drug benefit and later voted against expanding it. He now proposes to make Medicare beneficiaries pay different amounts for Part D, depending on their income.
- Learn more: www.health08.org; "The Truth About the Drug Companies," the New York Book of Reviews
7. GENDER-BASED HEALTH DISPARITIES
Heart disease, depression, osteoporosis, STDs and autoimmune diseases are just a few of the health conditions that disproportionately affect women. Disparities are even greater for low-income women and women of color.
- Solutions: Conduct more research on the biological links to health, allocate more funding for research on women's health, and include more women in medical studies.
- Obama's position: Obama supports legislation to examine gender health disparities and increase low-income women's access to health services. He has been an advocate for the Centers of Excellence in Women's Health at the Department of Health and Human Services.
- McCain's position: McCain has been silent on this issue.
- Learn more: Society for Women's Health Research, Women's Health Research at Yale, Office of Research on Women's Health
8. HIV/AIDS
More than 33 million people worldwide have AIDS. There is no cure for the disease, and according to the World Health Organization, approximately 2.1 million people -- including 330,000 children -- died from it in 2007. That same year, 2.5 million people were newly infected. In the United States alone, 1 million people are living with HIV/AIDS, and racial/ethnic minorities are disproportionately affected. AIDS was the fourth-leading cause of death among African-Americans ages 25 to 44 in the United States in 2004.
- Solution: Battling HIV/AIDS is a tremendous challenge that will require a multi-prong strategy that addresses the disease as it relates to health, foreign policy, race, gender, income inequality, education, etc. Among the steps needed, the next president of the United States should do the following: Fund additional research for HIV/AIDS prevention and treatment; make sure infected populations have access to affordable care; and fully fund family planning programs and revise PEPFAR, the President's Emergency Plan for AIDS Relief, which combats the disease on a global scale.
- Obama's position: Obama has developed a detailed strategy to fight AIDS both domestically and globally, which includes but is not limited to fixing the U.S. health care system, bringing Medicaid coverage to low-income HIV-positive Americans, fighting disparities in minority communities, promoting prevention, expanding funding for research, revising PEPFAR, increasing contributions to the Global Fund, reducing poverty and closing the education gap. In response to a CDC report on HIV/AIDS, Obama said, "Combating HIV/AIDS also demands closing the gaps in opportunity that exist in our society so that we can strengthen our public health. We must also overcome the stigma that surrounds HIV/AIDS -- a stigma that is too often tied to homophobia. We need to encourage folks to get tested and accelerate HIV/AIDS research toward an effective cure because we have a moral obligation to join together to meet this challenge, and to do so with the urgency this epidemic demands." Read Obama and Biden's entire HIV/AIDS plan.
- McCain's position: McCain has not put forth a formal strategy to fight AIDS domestically or globally. He does support global AIDS efforts through PEPFAR but has not called for it to be revised. In response to a CDC HIV/AIDS report, he made this statement: "As president, I will work closely with nonprofit, government and private-sector stakeholders to continue the fight against HIV/AIDS. By focusing efforts on reducing drug costs through greater market competition, promoting prevention efforts, encouraging testing, targeting communities with high infection rates, strengthening research and reducing disparities through effective public outreach, we as a nation can make great progress in fighting HIV/AIDS."
- Learn more: CDC, World Health Organization, www.health08.org
9. VETERANS' HEALTH
A recent report from the RAND Corporation revealed that nearly a fifth of military service members returning from Iraq and Afghanistan have symptoms of Post Traumatic Stress Disorder or major depression. Suicide attempts among American veterans have reached catastrophic levels, with one widely reported estimate by the Department of Veterans' Affairs determining that 1,000 vets try to kill themselves every month; about half of those attempts end in death. The VA's attempts to conceal this and other alarming statistics -- as well as its attempt to
reduce the number of diagnoses of PTSD, revealed by Citizens for Responsibility and Ethics in Washington and VoteVets.org -- has sparked outrage at a time when the VA is already embroiled in a scandal over its systematic blocking of veterans benefits. In 2004 alone, the last year for which data are available, 6 million veterans and their families had no health care. With American soldiers serving multiple tours of duty to maintain troop levels in Iraq -- and with thousands now scheduled to be shipped to Afghanistan -- the problem will likely only get worse.
- Solution: Provide veterans with full health benefits and resources to help them get their lives back on track.
- Obama's position: As a member of the U.S. Senate Committee on Veterans' Affairs, Obama passed legislation to improve care for wounded veterans and helped to pass laws designed to help homeless veterans. As reported by TalkLeft, Obama led a "bipartisan effort to halt the military's unfair practice of discharging service members for having a service-connected psychological injury." He also supported the Webb GI Bill, which was critical to providing educational opportunities for veterans. Obama has an 80 percent approval rating from the Disabled Veterans of America and has received a B+ rating from Iraq and Afghanistan Veterans of America.
- McCain's position: John McCain voted against health care funding for veterans in 2003, 2004, 2005, 2006 and 2007. The Disabled Veterans of America gave McCain a 20 percent approval rating, and he has a "D" rating from Iraq and Afghanistan Veterans of America. A rundown of some of McCain's specific votes is revealing: In September 2007, McCain voted against the Webb amendment, which called for adequate troop rest between deployments. In 2006, McCain was one of only 13 senators to vote against $430,000,000 for the Department of Veteran Affairs for medical services for outpatient care and treatment for veterans. McCain joined President Bush in opposing the Webb GI Bill because he felt it would hurt retention by offering veterans an opportunity to go to college. (He then reversed his position and tried to take credit for the bill.)
- Learn more: Vietnam Veterans of America: PTSD, Iraq Veterans Against the War: Health Fact Sheets, Veterans for Peace
10. REPRODUCTIVE HEALTH AND FAMILY PLANNING
The ability of a woman to choose the number and spacing of her children is fundamental to gender equality, women's health, and the health of families, communities, economies (local, national and international) and the environment. Publicly funded family planning clinics, which provide women with the resources -- contraception, health services, abortion counseling, etc. -- to do this are in danger. While 89 percent of the voting public supports publicly funding these services, Title X funds, which make a wide variety of health care services available to lower-income families, have not kept pace with medical inflation. As more and more individuals become uninsured, these strapped-for-cash clinics are unable to meet that rising demand and, in some cases, are closing.
Download this Voter Guide as a .PDF
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