For Democrats, the goal is universal coverage, whether immediately mandated or phased-in. Senators Hillary Clinton (D-NY) and Barack Obama (D-IL) have both proposed tax breaks and other incentives to help individuals obtain health insurance, as well as calling for expansion of Medicaid and the State Children's Health Insurance Program (SCHIP) to cover more children and low-income adults.
Interestingly, Sen. John McCain (R-AZ) is the real radical in the debate, having suggested a shift from employer-based coverage to a system that relies on individuals to obtain insurance. McCain proposes to end tax advantages for employer health benefits, and use the savings for tax credits and subsidies that make coverage more affordable. The GOP leader also backs "means testing" for Medicare, and wants to scale back the program's drug benefit to reduce government subsidies for "the Warren Buffets of the world."Cutting costs
The candidates' proposals to expand health programs and extend tax breaks will be expensive, carrying price tags in the range of $150 billion to $200 billion a year. The White house hopefuls say they'll pay the bill by cutting healthcare costs, but most of their plans carry high price tags. [See sidebar, pg. 38.]
Consequently, the candidates are talking about reducing expenditures for prescription drugs. Obama has called for US consumer access to the "exact same drugs" sold in Europe and Canada at half the price, and wants to "prohibit big name drug companies from keeping generics out of the market." He expects to save up to $30 billion by repealing the ban on government price negotiations for drugs purchased by Medicare—a policy he described during the Pennsylvania primary campaign as a congressional payoff to Big Pharma.
Similarly, Clinton vows to hold down fast-rising drug prices by removing barriers to generic competition and allowing Medicare to negotiate lower drug prices. In addition, she wants to boost oversight of drug advertising and "marketing excesses," including public reporting of "inappropriate" financial relationships between pharma and providers, and curbs on sale of physician prescribing data to manufacturers. Clinton also proposes creating a pathway for biogeneric competition and increased funding for FDA's Office of Generic Drugs.
Anti-pharma rhetoric is coming even from McCain, who sees generic competition and drug re-importation as being compatible with a market-based healthcare system. The presumptive Republican nominee wants to increase the number of routes for "safe, cheaper generic versions of drugs and biologic pharmaceuticals" to come to market, and develop safety protocols that permit re-importation to keep competition vigorous.
Politicians have also suggested tying cost control strategies to "objective" and "accurate" information about the effectiveness of medical treatments in real-world care settings. McCain says that publicizing information on treatment options and developing national standards for measuring and recording outcomes will help address the rapidly rising cost of US healthcare. Clinton advocates independent research to compare the effectiveness of treatments, in order to address the huge growth in prescription drug use. Obama wants competitive effectiveness (CE) research on the value of drugs, devices and procedures for individual patients to reduce the "considerable waste in our healthcare system."
Indeed, the campaign for CE enjoys broad support. In June 2007, the Medicare Payment Advisory Commission recommended that Congress establish an independent entity to sponsor "credible research on comparative effectiveness of health care services." [See PE, "Washington Report," June 2007.] And in January 2008, an Institute of Medicine (IOM) committee backed a national CE assessment program with "sufficient resources, authority and capacity" to develop research standards and processes. An IOM Roundtable on Evidence-Based Medicine provides a forum for discussing ways to improve medical evidence and its use.