WASHINGTON -- It is a shame that a discussion of health care policy has come near the end of the presidential campaign, when the level of discourse is at its lowest.
In the midst of assailing John McCain's mental health -- he is diagnosed as both "erratic" and "out of touch" -- Barack Obama and Joe Biden have pressed an attack on McCain's health care plan that is deceptive in almost every detail.
McCain has proposed to replace the current government health care subsidy for employers with a tax credit that would help all individuals and families purchase coverage. Biden terms this the "largest tax increase in the history of America for the middle class." He is off by -- well, by even more than the norm of Biden hyperbole. In fact, the McCain trade-off would result in a significant tax cut for nearly everyone (except those with the highest incomes).
Obama breathlessly reveals that the McCain credit "wouldn't go to you. It would go directly to your insurance company." Since the credit is intended for the purchase of health insurance, where else should it eventually go? Is it a scandal that a child care credit eventually goes to child care centers?
"At least 20 million Americans," charges Obama, "will lose the insurance they rely on from their workplace." As Yuval Levin of the Ethics and Public Policy Center points out, this is a distortion. He cites a Tax Policy Center estimate that the McCain plan would result in 21 million people entering the individual insurance market by 2018 -- many because individual ownership of insurance will be more attractive. In every mainstream analysis, McCain's plan would result in a net increase in the number of the insured.
Obama terms the McCain plan "radical" -- which is its main virtue. It goes to the root of the problem -- a system that depends mainly on businesses to provide health coverage. Over the last few decades, the rising cost of health coverage to employers has eaten up pay increases, acting as a wage cap and leaving many incomes stagnant or falling. Business-based health coverage leaves many workers afraid to change jobs -- a handicap in the constant employment churn of the new economy. It discriminates against the self-employed and places unique burdens on small businesses. And it insulates workers from decisions about health care costs. Few in the current system benefit from searching out the best health care prices and results.
There are really only two visions of health care reform: using government to increase private insurance coverage, or using government to provide health care on a larger scale. McCain takes the first approach. Obama takes the second. Under Obama's plan, medium and large employers would be forced either to give coverage to employees, or pay into a new government program, modeled on Medicare, which would provide public insurance. This may sound like a fair competition between public and private, but it isn't. Unlike private companies, government can cut costs through imposing price controls and shifting costs to others (just as Medicare does). Over time this would give the government an unfair price advantage over private insurance, causing more and more businesses to pay into the public program.
Obama's health plan is really slow-motion Medicare for all. And the problem with Medicare-like price controls is that they reduce the number of people willing to provide medical services, which always means longer lines and rationing.
McCain's health plan has a problem of its own. It is not too radical, but too timid. A $5,000 per family, refundable tax credit -- in addition to increased cash wages from employers no longer burdened with paying for health care -- would help middle-class workers get insurance. But for people on the lower end of the scale -- who don't qualify for Medicaid -- the $5,000 credit alone would not be enough to buy adequate coverage, which can cost more than double that amount.
To be a genuine alternative, Republicans should follow their own logic and make the ownership of private health insurance an entitlement. Fund the purchase of a basic health insurance plan completely, through a refundable tax credit, so every low income American can afford insurance. Help consumers exercise their newfound choice of health plans by requiring the disclosure of comprehensive information on health costs and outcomes.
Universal Medicare is a frightening prospect. But it may be unavoidable unless Republicans can counter the rallying cry "Health care for everyone" with a simple and superior alternative: "Health insurance for everyone."