Michael Arnold Glueck, M.D., and Robert J. Cihak, M.D.
Tuesday, Mar. 16, 2004

So, it's time once again to compare the presidential candidates' approaches to American health care.

In his State of the Union address this year, President Bush said, "A government run health care system is the wrong prescription. By keeping costs under control, expanding access, and helping more Americans afford coverage, we will preserve the system of private medicine that makes America's health care system the best in the world."

Senator Kerry, not surprisingly, would get the federal government more deeply involved in many ways. He wants the government to pay for 75 percent of health care costs over $50,000 for insured employees, thus aiding employers. But employers would have to follow a number of government mandates in order to qualify for this subsidy, such as to "provide affordable health coverage to all of their workers."

However, if history is any guide, the government is likely, long-term, to cut back on payments even as it lays more requirements on businesses buying into the plan. This is happening today with Medicare and Medicaid.

In Medicare, the federal government ratchets down spending while pretending that access to care and quality can be maintained. It can't. It happened with federal funding for hospital construction; the government continued to mandate requirements on hospitals decades after hospitals had spent the construction money.

Senator Kerry would also establish more government programs and increase the size of ones already in place, for example Medicaid and the State Children's Health Insurance Program (S-CHIP).

President Bush says he's pushing for more consumer choice in health care. For example, the 2003 Health Savings Account (HSA) legislation encourages people to use their own tax-free savings, because people using their own money to buy health services causes doctors and hospitals to pay attention to the patient rather than the insurance company.

This is especially true when medical services, such as cosmetic surgery and laser eye surgery, are not covered by insurance. Interestingly, in these cash-dominated "elective" specialties, quality has gone up while costs have gone down.

In health insurance, President Bush says "The more competition the better." In addition to Health Savings Accounts (HSAs), he promotes association health plans, where groups of affiliated people (such as church, business or fraternal groups) could negotiate insurance packages for members, just like employers. This implies he would promote a federal law to preempt the many state laws which effectively make this impossible.

Senator Kerry, meanwhile, has adopted part of a Heritage Foundation proposal and would allow "all Americans" to join the Federal Employees Health Benefits Program (FEHBP), especially individuals and employees of large businesses. As Kerry says, federal employees have "a wide choice of affordable health plans with group protections and good benefits." Insurance companies compete vigorously.

Unlike Medicare and Medicaid, the FEHBP allows federal employees options in coverage and premiums. Also, national FEHBP plans pre-empt health insurance mandates in state law, greatly simplifying designing and comparing health plans.

At the same time, Kerry proposes reforms to "keep Medicare strong, instead of privatizing it." This implies that the private purchasing and competition inherent in the FEHBP wouldn't apply to Medicare recipients but that these seniors will have to deal with an even stronger and more stringent bureaucracy.

Kerry's package of proposals puts a $72 billion per year price tag on his changes. These, he claims, "would provide health care coverage to nearly 27 million Americans who were previously uninsured, while making health care more affordable for millions of others." He doesn't break down most of the costs, however, so it's impossible to tell where the numbers come from. However, we can be quite sure that the cost estimate is way low.

Indeed, the whole history of state medicine shows the same pattern. Initial estimates of costs are so incredibly understated that not even the advocates believe them. As costs skyrocket, it becomes necessary to at least pretend to constrain them.

This is done in two ways: by micro-management (read here, endless paperwork and criminal prosecutions) and rationing, i.e., withholding care. And yet, the politicians and the people keep repeating the process. Why?

The answer is "affordability." To you and me, what's affordable is determined by two factors: what we need, and how much money we have. If we're rational, we prioritize our needs, and then spend the money accordingly. But to the government, "affordable" means something entirely different.

Affordability is determined by what's needed to keep their racket going. As for the money . . . well, that comes from somebody else. When politicians talk about affordability, they're not talking about what they can afford; they're talking about how much money they'll force you to spend to keep them employed.

Of course, Congress and changing times will modify any proposal. But the direction each candidate would go is clear from their past actions and votes. Kerry believes in more government control over your choice of health plan, doctor and other health services; Bush believes in more individual choice and freedom.

Editor's Note: Robert J. Cihak wrote this week's column.

Robert J. Cihak, M.D., is a Senior Fellow and Board Member of the Discovery Institute and a past president of the Association of American Physicians and Surgeons. Michael Arnold Glueck, M.D., is a multiple award winning writer who comments on medical-legal issues.