Feature US health care

Health and the US presidential campaigns

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1672 (Published 23 September 2008) Cite this as: BMJ 2008;337:a1672

This article has a correction. Please see:

  1. Barbara Markham Smith, consultant to Health Management Associates
  1. 1Washington, DC 20037, USA
  1. bsmith{at}healthmanagement.com

    The ways Americans get insurance, the costs they bear, and their access to health care will all be affected by the plans of the presidential candidates. Barbara Markham Smith describes the implications of the two proposals

    John McCain and Barack Obama offer two very different visions of the healthcare future.1 2 While neither moves to a single payer system that provides automatic universal coverage, there is a substantial spectrum between single payer and the current predicament in America.

    Tale of two markets

    Americans who have employment based insurance receive a substantial tax subsidy since the dollar value of their insurance benefits is not counted as taxable income. There are also other benefits. Employers buy their insurance in group markets, which are not only cheaper but do not subject individual employees to medical underwriting—discrimination through higher prices and exclusions from coverage based on actual or predicted medical needs. Therefore, people with employer based insurance have better access to insurance. In addition, the group policies generally offer more substantial benefits than individual policies. Often, employer plans have lower initial out of pocket costs, more preventive benefits, and better protection against catastrophic costs.

    Americans whose employers do not offer health insurance do not receive the automatic tax subsidies to purchase insurance that come with employer plans and thus bear the full cost. Buying their insurance as individuals, they generally have access to fewer benefits, pay the highest administrative costs as a percentage of premiums, and face the most aggressive medical underwriting.3 Premiums in the individual market can be as high as five times the average premium of roughly $12 000 a year in the employer market.4 5

    McCain proposal

    Mr McCain proposes to eliminate the tax benefits of employer sponsored insurance. This means that the dollar value of the insurance will be taxed as income. The better …

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