Barack Obama is conservative. John McCain is radical.
It's true, at least with respect to one issue: healthcare.
The dysfunctional state of healthcare delivery combined with rapidly escalating costs have framed the issue to be one of the most visible in the 2008 election season. Which party has the edge? Democrats have historically enjoyed large advantages in polls declaring that people "trust" them more than Republicans by wide margins. But there are unusual dynamics at play this time around.
A 2007 poll found a majority of respondents in favor of a single-payer government healthcare system, while 77 percent simultaneously supported "reducing government regulation of insurance." This seemingly contradictory finding points to the fact that disgust with the current system overrides affinity for any particular reform agenda. As the Cato Institute's Michael Tanner puts it, "Voters are saying that almost anything is better than the status quo."
In this climate, the conventional Democratic edge may not hold up. The field is wide open for whoever touts the more attractive reform package.
For all the talk of universal health care, Barack Obama's proposals actually move us only slowly and not very far in that direction. He would enact government mandates requiring employers to insure their workers and parents to insure their children, while introducing extensive new regulations of the insurance sector, such as requiring health plans to cover all applicants. Even with these changes, however, Obama's plan essentially preserves the employer-based system that has proved so troublesome.
By comparison, McCain's reforms look radical. He calls for moving away from the employer-based system by shifting insurance tax credits from employers to individuals, giving people more control – and thereby more responsibility for – their own health care. Additionally, he proposes deregulating the insurance market, so that interstate competition increases.
Both schemes must deal with the question of financing, but there is another important question to pose. Most Americans are concerned that healthcare provision be characterized, not only by economic efficiency, but also by justice and equity. When vulnerable populations don't have access to adequate healthcare, our obligations to the common good stand unfulfilled. Which plan aligns better with the demands of justice?
It is difficult to predict what the results of either approach would be. As incentives change, behavior changes, making calculations hazardous. Both McCain and Obama recognize that a problem as enormous as healthcare delivery is not easily soluble by a single reform program. But if we're at a crossroads considering whether to move toward more government involvement or more market freedom, the latter direction is likely to lead toward a more efficient and equitable system.
History proves that large government programs covering high numbers of beneficiaries with diverse needs do not fare well. At the personal level, bureaucratic rules replace individual care and attention. At the economic level, price control would almost certainly be part of the package. Price ceilings, as long lines for gasoline in the 1970s should have convinced us, lead to shortages of supply. The generation of fewer doctors and nurses is not a prescription for improved healthcare.
The drawback of the market is its potential for unequal outcomes. It is important to remember, however, that inequality is not synonymous with injustice. Justice does not require that all people receive precisely equivalent levels of medical treatment; instead, it dictates that basic physical needs, including healthcare, are met. Perfect equality, moreover, is simply unrealistic. Even in those nations held up as models of universal access – Canada, for example – the wealthy and well-connected manage to secure better or faster medical treatment.
The more critical concern is that the people who are most vulnerable – children, the unemployed, the uninsured, the chronically ill – may fall through the cracks of a healthcare market built on a foundation of personal responsibility. This is where other institutions play indispensable roles. Many of America's hospitals bear testimony to their religious roots: Mercy, Methodist, Good Samaritan. Provision of care for the ill has ever been intrinsic to the practice of Christianity, reflected in the traditional work of mercy, "visit the sick."
Neither presidential candidate's reform plan highlights the extensive work performed by charitable organizations, but neither the market nor the government is going to care adequately for those on the margins. Whichever reforms (if any) are eventually implemented, the imperative to visit the sick will remain as a call to each of us to lend support in our families, churches, and communities.