By proposing to move away from the employer-based health care system to one emphasizing the individual market, Sen. John McCain (AZ), the presumptive Republican presidential nominee, has set the stage for health care to become part of a major debate about government and the marketplace during this year’s election, Robert Blendon said May 5.

Blendon, a professor of health policy and political analysis at Harvard University and director of the Harvard Program on Public Opinion and Health and Social Policy, spoke during a conference call moderated by Health Affairs editor-in-chief Susan Dentzer on the role of health reform in the presidential election. Other participants included Robert Laszewski, the president of Health Policy and Strategy Associates Inc. and the author of the widely respected blog Health Care Policy and Marketplace Review; and Julie Rovner, a health policy correspondent for National Public Radio and a contributing editor for National Journal’s CongressDaily. Health Affairs organized the call in connection with the publication of its May/June issue, a thematic issue on health reform. Click here for the full transcript of the call.

Blendon said the majority of voters in the 2008 election will not have graduated from college and will not vote based on policy details such as the presence or absence of an “individual mandate” requiring people to purchase insurance. Nevertheless, he said, people are frustrated with the absence of real debate so far in the presidential campaign, and the issue of health care reform offers the sort of thematic distinctions that are understandable and important to most voters.

“So what’s going to happen is a small number of issues, on which the candidates’ positions can be easily understood as fundamentally different, are really going to be debated, and health care is going to be one of them,” said Blendon, who named trade as another issue that would be part of the philosophical debate. “And Senator McCain has framed this in a way that people can make a real choice. Do you want basically individuals in the marketplace, or do you want government fixing the employer system? Do you want something big done about the uninsured or not? And he put it in a way that someone didn’t have to have gone to college to understand what that debate is about.”

How will this debate be resolved? “My gut tells me that people will lean more towards the security of the Democratic side,” said Blendon. Rovner agreed. She recounted the surprisingly overwhelming support she found for a single-payer system among a Kansas crowd: “It’s not just a matter of people wanting the security of what they have now. People, if anything, want to go more towards the government and less towards the market.” Rovner said she was “not suggesting that there is a groundswell of a majority for a single-payer system. But I am suggesting that as people see costs go up, I think they are looking more towards the government and less towards the private market as a way to protect themselves.”

Vulnerabilities: For McCain, It’s Reassuring Those With Chronic Diseases; For Democrats, It’s Avoiding The “Tax-And-Spend” Label

Laszewski said McCain had left himself needlessly open to Democratic attacks because of the nature of his proposal to ensure coverage for those with chronic diseases and other pre-existing conditions, a group that has historically found it difficult or impossible to obtain coverage in the individual market. McCain proposed that the federal government help fund state “high-risk” pools to cover these hard-to-insure individuals, and he said he would work with the governors after being elected president to discuss the details of setting up “guaranteed access plans”, or “GAP” plans

“I can’t believe his GAP proposal,” said Laszewski, who spent 35 years in the insurance industry. He said McCain had a number of solid ways available to guarantee coverage for those with pre-existing conditions: “We just did it with the Medicare Part D drug benefit. We just offered an individual policy, voluntary to the marketplace, and covering people’s pre-existing conditions — and people over sixty-five have a lot of pre-existing conditions.”

McCain’s actual proposal would make it easy for Democrats “to scare the hell out of voters,” according to Laszewski. Voters “can easily understand that high-risk pools have never really worked well before. The Democrats can show any number of train wrecks in that regard. And ‘I’ll figure it out after the election, trust me’” won’t persuade voters to abandon the security of the employer-based system, Laszewski predicted.

However, the Democrats have their own large vulnerability on health care, said Rovner. McCain will be able to criticize either Barack Obama’s or Hillary Clinton’s health plan as “tax and spend” because “the idea that you can pay for these plans by simply letting the Bush tax cuts expire does not hold up, and the Democrats know it and McCain knows it. If you want to do the Democrats’ plan, you’re going to have to raise taxes.”

In contrast, the Congressional Budget Office recently scored a health reform bill sponsored by Sens. Ron Wyden (D-OR) and Robert Bennett (R-UT) as revenue-neutral, meaning that it would not impose additional costs and would not necessitate additional taxes. Laszewski suggested that this bill could provide a compromise vehicle, particularly if voters deliver a split verdict by returning a Democratic Congress but installing John McCain in the White House: “Wyden-Bennett gives everybody something. It moves the system from the employer-based system, the third-party payment system that Conservatives are very worried about, to an individual system, but an individual system with a pretty good safety net, and a financing mechanism.”

In short, according to Laszewski: “Watch Wyden-Bennett.”