US Healthcare and the 2008 Presidential Primaries

NOVEMBER 19, 2007

Dear Colleague,

Do you know whom you will be voting for in the presidential primaries? Do you know that candidate's view on healthcare, including universal coverage? We will not take a stance on whom to vote for in this column, but we want you to do so. If you are not demanding health plans from your presidential candidate, you are doing yourself and our nation a disservice.

That's a pretty aggressive statement. What about Iraq? Homeland security? Social Security? Those are all important, but the United States spends more on healthcare than on all those issues combined.1-3 Perhaps you look at health expenditures as private industry, which it partially is. But if you include the cost of the tax exclusions of healthcare, along with that of Medicare and Medicaid, more than 50% of all US health expenditures are made by our government.4,5 Only in 4 countries (China, Japan, India, and Germany) does the entire gross domestic product exceed what the United States spends on healthcare.7 Despite that level of spending, 1 in 7 Americans is uninsured today, according to the American Medical Association (AMA), which has so poignantly said, "1 out of 7 is 47 million too many." It is estimated that more than $100 billion is currently spent on the uninsured.5 When you help our nation choose our next leader, these facts should influence you not only to learn everything you can about the candidates' stances on healthcare, but when you find deficiencies, you should demand remedies.

We chose not to lay out all the presidential candidates' plans to avoid oversimplifying them, for lack of space (thereby doing you and the candidates a disservice). After all, what may seem a good plan in a few sentences often falls apart when fleshed out. Some candidates do not yet have a plan, and many of the plans are not fully developed.

It is more valuable to help you steer through the hype and headlines. Tax incentives, for example, are often demonized by "the left" as a means of only benefiting the rich, instead of extending care to those who need it. Tax incentives could indeed be misused this way, and certainly are in today's tax structure. You and I are paying significant taxes to provide health insurance for the wealthiest Americans. This is because, when we buy our insurance tax-free through our employers or businesses, it is those in the highest tax bracket (eg, millionaire athletes and CEOs), who can afford the most health insurance and therefore get the greatest benefits. For example, some companies pay $100,000 of the health expenses for the family of each top executive.8 Because these executives are in the 35% tax bracket, $35,000 of this free medical coverage is tax-free. We foot the bill. In contrast, poor people get little or no benefit from this structure, which redistributes income from the poor to the rich. Some candidates are putting forward healthcare plans that would worsen this inequity.

But tax incentives can be properly used to create a universal goal. Imagine a tax credit inversely proportional to income, such that a wealthy person will get nothing, and those who have no income will get a check from the government that will cover the entire cost of their healthcare (and all income levels in between). Tax incentives are not necessarily bad for the poor or good for the rich; they can be structured to accomplish anything. Do yourself a favor and read the details rather than believe the hype.

Another example is "socialized medicine," a term that is sometimes misrepresented by "the right" in an effort to steer the discussion about healthcare. The debate surrounding socialized medicine needs to focus on what role you believe the government should play in ensuring that all Americans receive healthcare. At first blush this may seem an easy question, but it becomes complicated by ideological differences about how to achieve that coverage. It is critical to separate funding from regulatory control. The government could hand each of us a check to purchase our own healthcare—this would be an entirely publically funded healthcare system, but one in which the individual wields total control. Alternatively, some argue for a Canadian-style single-payer system, in which the government is not only the sole payer but also the physician's employer, the hospital owner, and the insurance provider. In terms of the financing, these 2 systems are both "socialized," but because of who has control, they have very different implications for physicians and their patients.

Another important question concerns the scope of funding: Should the government focus on the poor and needy who are currently without health insurance, or should the funding be distributed to us all? Should we still be paying for health insurance for the very rich? If your answer is no—where would you draw the line? There are arguments on both sides about how this will affect quality, cost, access, and so on.

The AMA believes that rather than a single-payer system that potentially limits patient choice with a one-size-fits-all approach, a public? private partnership that builds on the strengths of our current system can create a uniquely American solution that would work for all. Indeed, although a single-payer system is one way to accomplish universal coverage, it is certainly not the only way. Instead of getting distracted by the rhetoric, concentrate on the percentage of the population that will be covered by a proposed plan, and what rights patients and physicians would have in that particular system.

The AMA first and foremost wants you to approach the primaries with the issue of the uninsured in mind. One in 7 Americans isn't just a statistic, it is a tragedy. It is an injustice. It is a national embarrassment. Most important, it is fixable. So although the AMA has its own plan to accomplish universal coverage, the first goal is to get everyone insured.

The AMA's plan is based on 3 pillars:

  1. Give people the choice of plans that they deserve.
  2. Based on need, give people enough funds to purchase their care.
  3. Create market reforms to ensure that this system can be enacted and will work.

So what can you do? Educate yourself about the candidates and their plans. If you attend a town hall event or a debate and can ask questions, demand that the candidates take positions and promise to move the issue. Go to, sign the petition, and make sure your voice is heard. Most important, vote, and when you do, do so informed about a candidate's view on healthcare and the recognition of our need to get everyone covered—for their own health and the health of the nation.

David A. Rosman, MD, MBA
Lahey Clinic, Department of Radiology
Speaker, Resident and Fellow Section—American Medical Association

Stephanie Stanton, MD
Vice-Speaker, Resident and Fellow Section—American Medical Association


  1. Office of Management and Budget. Budget of the United States government, FY 2006. Available at Accessed October 16, 2007.
  2. 2006 budget proposal: agency breakdown. Washington Post. February 5, 2007. Available at Accessed October 9, 2007.
  3. Robinson MD, Mandel BA. Federal budget estimates for fiscal year 2006. Survey of Current Business Online. March 2005. Available at Accessed October 16, 2007.
  4. Sheils J, Haught R. The cost of tax-exempt health benefits in 2004. Health Affairs. Web exclusive. February 25, 2004. Available at Accessed October 16, 2007.
  5. National health expenditure projections 2006-2016. Available at Accessed October 16, 2007.
  6. International Monetary Fund. World economic outlook database, April 2007. Available at Accessed October 9, 2007.
  7. National Coalition on Health Care. Health insurance coverage. Available at Accessed October 9, 2007.
  8. Schultz EE, Francis T. The CEO health plan. The Wall Street Journal Online. April 13, 2006. Available at Accessed October 16, 2007.

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