Health Care Reform in the 2008 US Presidential Election

Abstract

As in Canada, the challenges of health care reform are a constant political refrain in electoral battles in the United States. Since the 1940s, in fact, successive presidential elections have been marked by the issues of health care access, cost, and coverage. The failure of Harry Truman's fair deal proposals and the success of Lyndon Johnson's great society project both had core visions for health reform, while the more recent challenges faced during Bill Clinton's first term in office underscore the persistent problems in addressing health care issues in the US.1The 2008 election year lived up to its promise of political spectacle, with a showdown between Hillary Clinton and Barack Obama for the Democratic nomination, and the fresh image of Sarah Palin recasting the Republican ticket with John McCain. In the vortex of the personality politics that dominated the campaign, it remained important not to lose perspective on the real political issues of the contest. The policy stakes between the parties were real and salient for voters and candidates alike. And although the economic crises of the fall 2008 would dominate headlines, health care reform remained a main ballot box issue in the November election.HEALTH CARE IN THE 2008 CAMPAIGNIn most US political contests, pocketbook issues tend to dominate voter concerns, particularly in worsening economic times. Members of the babyboom generation have become increasingly insecure about their health-care future as costs soar and even middle-income Americans remain worried about being able to afford health care.The stakes also are high for businesses grappling with how to insure workers in an economic downturn and how to compete with firms in other countries - including Canada - that don't have to shoulder that burden directly. Yet even though a good number of business leaders recognize the need for health reform, the business community remains divided on the nature of needed change and has been unable to sustain or support concerted legislative efforts.2Moreover, the persistent problem of the uninsured - 47 million at last count - haunts every political candidate.3 Why the US can spend so much on health care and yet have so many residents uninsured has led to a lively scholarly debate, but the question of the uninsured is of key practical concern as well .4 This is because access to health care in the US depends on insurance coverage, not citizenship, as is the case in practically every other industrialized country.In fact, in the United States today, in sharp contrast to Canada, access to care is not guaranteed. Instead, access to care depends on one's insurance coverage, which varies widely between individuals and is determined by state of residence, employment status, financial capacity, age, and disability. Most Americans (and their dependents) are covered through voluntary employment-based health insurance, in which they share in paying the costs of premiums with their employer. A small minority carry individual private insurance.So, while Canadians bemoan rising taxes and politicians fret about increases in health care budgets, our concerns are largely about the collective impact of rising health care costs. In the US, meanwhile, those costs are felt directly in people's wallets. As the economy tightens and the potential for unemployment rises, so too does the possibility of losing coverage. But financial squeezes also come into play for the employed, since many low-wage workers cannot afford to pay health insurance premiums, while most part-time workers are not offered those benefits at all.As in Canada, health care reform in the US is also about government programs, public spending, and fiscal federalism. This is because government involvement in health care is substantial, through major federal legislation instated in the 1960s, through tax subsidies for health insurance for employees and the self-employed, and through extensive regulations of insurers and health maintenance organizations. …