Slugging it out over health care, stem cells, and abortion

BMJ 2004; 329 doi: (Published 09 September 2004) Cite this as: BMJ 2004;329:592
  1. Janice Hopkins Tanne
  1. New York

    With the US election scheduled for November, Janice Hopkins Tanne analyses the differences in health policy between the Republicans and the Democrats

    “We are delighted we have good health insurance. That makes a big difference. And I hope some day everybody will be able to say the same thing,” said Democrat senator Hillary Rodham Clinton when her husband, former president Bill Clinton, entered New York's Presbyterian Hospital for bypass surgery last week.

    Senator Clinton pointed to a major issue in the 2004 American elections: 45 million people lack health insurance and many others fear losing insurance in an uncertain economy.

    “The Republican and Democratic party platforms [on health insurance] are very different,” Dr Karen Davis told the BMJ. Dr Davis, who is an economist and health policy analyst and heads the non-profit Commonwealth Foundation in New York, said that Democrat candidate Senator John Kerry's programme “is more comprehensive and more expensive. It would cover about 27 million of the uninsured. [Republican] President George W Bush's plan would cover two to six million.”

    How the parties propose to increase coverage

    The Bush plan increases coverage mostly through incentives for people to buy health insurance. The plan also expands some public programmes for children and poor people and increases the number of community health centres that provide medical care to children and poor people in minority communities and rural areas.

    View this table:

    The Kerry plan would greatly expand public programmes and set up public-private programmes to enrol millions in a plan like the one paying for Mr Clinton's heart surgery.

    The American College of Preventive Medicine said that the Bush plan might cover 13 million of the uninsured population. It has a comparison of the Bush and Kerry positions on health care on its website ( The college does not endorse either candidate and said neither plan reaches the goal of universal access (

    Dr Davis said the Kerry plan could cost $70bn (£39bn; €58bn) a year, or $653bn to $895bn over 10 years. The Bush plan would cost $7bn-$8bn a year, or $80bn-$100bn over 10 years. The Republican platform does not say how it would finance the costs.

    The Democrat plan would repeal Bush's tax cuts for people earning over $200 000 a year. It also proposes that the federal government take over responsibility for Medicaid costs for children's care from the states and that the federal government provide reinsurance for catastrophic medical costs, lowering insurance premiums for employers and individuals by 10%.

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    Kerry's healthcare plans are costlier but more comprehensive than Bush's


    Who pays: Republican plan

    For individuals and employers, the Republican platform proposes tax incentives to make it easier for individuals to buy health insurance.

    The Bush plan would allow employees to contribute to tax free health savings accounts while also requiring them to buy high deductible health insurance to cover medical expenses above an unspecified figure. The savings accounts would pay for medical care; the insurance plan would kick in when the individual's costs rose above the deductible. Advocates say people would be more aware of costs and eliminate frivolous doctor visits.

    For the self employed, the Bush plan would let people deduct from their tax bills the money they put into the health savings accounts—up to $1000 for individual people earning up to $15 000 and up to $3000 for families with an income of up to $25 000.

    Who pays: Democrat plan

    Senator Kerry's Democrat programme would cover many more people but would cost more. Incremental steps would lead to almost universal coverage.

    The plan calls for a major expansion of public programmes, to provide coverage for every child. The programmes would also cover low income parents.

    The Democrat plan would allow workers and small employers to join the federal employees' health plan to offer the same care that members of Congress receive.

    Both plans

    Both plans call for treating mental illness equally with physical illness, investing in electronic medical records to reduce medical costs and medical errors, protecting patients' privacy, improving quality of care, and encouraging people from minority groups to enter science and medicine.

    Both plans also call for reforms in the medical malpractice system to reduce lawsuits and reduce defensive medicine.

    The biggest differences

    The biggest differences between the platforms are on abortion and stem cell research. On abortion, the Republican platform elevates embryos and fetuses to the status of citizens. The platform says, “We support a human life amendment to the Constitution and we endorse legislation to make it clear that the 14th amendment's protections apply to unborn children.”

    The Democrat platform supports a woman's right to choose abortion—consistent with the Roe v Wade Supreme Court decision of 1973—regardless of her ability to pay. “Abortion should be safe, legal, and rare,” it says. The platform supports family planning and adoption incentives.

    On stem cell research, the Republican platform restricts federal funding to stem cell lines in existence on 9 August 2001. It would ban human cloning and the creation of human embryos.

    The Democrat platform calls for the reversal of Bush's “wrong-headed policy” and hails the promise of stem cell treatment in Alzheimer's disease, heart disease, juvenile diabetes, and Parkinson's disease. It supports stem cell research “under the strictest ethical guidelines.”

    The Republican platform is available at

    The Democrat platform is available at

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