Dissecting the Health Care Debate

What the candidates said and didn’t say

Both John McCain and Barack Obama were expected to pound away at health care during last night’s debate, and, indeed, they wove the topic into their answers to several of the questions they faced. The things they said (or didn’t say) offer important clues about how their respective plans for health care reform might unfold.

Right at the beginning, Obama said “long term, we’ve got to fix our health care system.” Yet he provided no timetable for getting an insurance policy in the hands of every man, woman, and child—which has been the cornerstone of his proposals. When Brokaw asked how the candidates would prioritize health care, energy, and entitlement reform, Obama said health care would come second, after energy: “Energy we have to deal with today, because you’re paying $3.80 here in Nashville for gasoline, and it could go up. And it’s a strain on your family budget, but it’s also bad for our national security.” His third priority would be education; he ducked the part about entitlements.

McCain said he would work on all three at once, but warned that entitlements might be on the chopping block: “My friends, we are not going to be able to provide the same benefit for present-day workers that we are going—that present-day retirees have today.” Translation: that could mean smaller Social Security checks and more out-of-pocket spending on health care for future retirees. Takeaway: Obama may take his time on health care; McCain wants to juggle lots of balls at once.

Brokaw returned to the question of entitlements, which means Social Security and Medicare, asking if, within two years of taking office, the candidates would give Congress a hard deadline for reforming both. Obama said that we have to address entitlements, and “I think we’ve got to do it quickly.” (I guess that means after energy, health care, and education, but not in the next two years.) Sometime in his first term is all he promised.

McCain had another idea: Let’s fall back on tried and true ways of Washington and establish a commission to study the problem and offer solutions. “My friends,” McCain said, “what we have to do with Medicare is have a commission, have the smartest people in America come together, come up with recommendations, and then, like the base-closing commission ideas we had, then we should have Congress vote up or down… let’s have the American people say, ‘Fix it for us.” Well, a decade ago a Medicare commission with some smart people on it did try to come up with recommendations—and failed, a point worth remembering. It’s worth asking how this commission would be different, and whether the American people want and should have a say in revamping one of the most successful and popular social programs the U.S. has ever devised. Takeaway: Neither candidate wanted to address exactly what he would do to shore up Social Security and Medicare, i.e. raise taxes or cut benefits.

The debate then got down to the health care nitty-gritty. From audience member Lindsey Trella came this question, that gets to the core of what American health care is all about: Do you believe health care should be treated as a commodity? Ah! Both candidates bailed on this one. Affirming his moral commitment to health care reform, Obama discussed various fixes for problems like high deductibles and co-payments, notably his plan to work with employers to reduce premiums by up to $2,500 a year. Although he has repeatedly cited this $2,500 savings figure, experts doubt that it will materialize.

McCain discussed his proposal—the now familiar $5000 tax credit and the need to make health care more efficient without government. He zeroed in on the fines that Obama would allegedly impose on small businesses that didn’t offer health coverage. The candidates’ responses to this question were great examples of media training at work—dodge what you don’t want to talk about and answer what you do. Takeaway: Neither candidate wanted to address how the U.S. health care is becoming a commodity to be bought and sold at this point—to those lucky enough to have insurance, that is.

Brokaw then asked the most telling question of all: Is health care in America a privilege, a right, or a responsibility? McCain responded: “It’s a responsibility, in this respect, in that we should have available and affordable health care to every American citizen, to every family member.” Then he again hammered away at how government mandates make him nervous; in other words, if the government doesn’t offer health insurance to everyone or mandate that people buy it, they assume responsibility for paying for their own care. Obama argued that health care was a right, and took a few jabs at the mandate question, touting his own plan along the way while making sure not to imply that he was promoting some great big government takeover of the health care industry. “Let me just repeat,” he said, “If you’ve got a health care plan that you like, you can keep it. All I’m going to do is help you to lower the premiums on it. You’ll still have choice of doctor. There’s no mandate involved.” Takeaway: Obama was very clear that health care is a right of every citizen, but very unclear about how everyone, not just the insurance-holding middle classes that he sought to reassure, would be able to secure that right. McCain’s comments suggest that health care is a personal responsibility, not a governmental responsibility.

How Americans and the candidates view Brokaw’s fundamental question says a lot about the challenges of reforming the system. We’ve finally abandoned the old-fashioned notion that health care is a privilege—an idea once peddled by the special interest groups. We may have become more enlightened, but this debate tells us there is still no consensus on who should provide health care.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.