Medical Device Daily Washington Editor

WASHINGTON — Healthcare is certainly on the national radar screen, especially in terms of the current run for the White House. And this year's World Healthcare Congress included a discussion of the healthcare proposals by representatives of the three candidates, Sens. Hillary Clinton (D-New York), John McCain (R-Arizona) and Barack Obama (D-Illinois).

In a replay of the kind of polling that goes on during party primaries — polling that suggests that many of the "undecideds" tend to remain undecided until the last gasp — a survey of the audience using wireless technology revealed that even the opinions of healthcare executives are malleable, seemingly shifting from moment to moment, depending on the particular rhetoric on a subject.

Leading off the discussion was Obama supporter Rep. Jim Cooper (D-Tennessee), although Cooper avoided discussion of many specifics, and spent most of his allotted time slamming McCain's proposal.

"Regardless of who wins this election, we simply must have federal healthcare reform this year," Cooper said, and that "[w]e must all work together to make sure we have insurance for every American."

Cooper described Obama as "the most exciting, most inspirational candidate of our generation." But he acknowledged that when it comes to a comparison, the Clinton and Obama health proposals aren't significantly different.

"If you look at this campaign, you'll see the Democrats are essentially unified" on the broad features, Cooper said, describing the differences between the two as "much ado about a technical subject" — perhaps referencing the fact that Clinton's plan would mandate enrollment for all Americans, whereas Obama's plan includes no such mandate.

"The big difference isn't between Democrats, but between Democrats and Republicans," Cooper said. McCain, he said, is "not for universal coverage, but universal access" that would be "so incremental that it almost gives incrementalism a bad name."

Of health savings accounts (HSAs), Cooper said that "expanded HSAs are not the medicine we need."

Democrats, he said, are "not for single-payer nationalized insurance," but are for "enhanced competition in the private sector."

Following Cooper's discussion, the electronic vote in the room showed that only 27% found Obama's plan feasible, the other 73% voting that it is not. The room was roughly evenly split on whether it would control costs.

McCain's advisor on healthcare policy, Thomas Miller, a resident fellow at the American Enterprise Institute (Washington), told the audience that "healthcare is a high priority" for the GOP nominee, and he urged the recognition "that business as usual is not sustainable."

McCain, he said, favors "realigned incentives to bolster competition" and "reinforce individual responsibility" for maintaining lifestyles that avoid health problems. The current system pays for services rather than outcomes, Miller said, a "value mismatch [that] puts price pressure on insurers and employers" alike. And Miller cautioned against any plan that does little more than insert more money into the existing system.

"Simply financing premiums" fails to change the dynamic, he said. "We need to improve cost, quality and coverage," or "our best efforts to expand availability and affordability will surely be frustrated."

McCain, he said, would seek to "reform payment systems to reward diagnosis, prevention and coordination of care," but added that none of this will work "without putting the American family at the center of the decision-making" nexus. A McCain administration would propose to "level the financial playing field," Miller said, by eliminating the tax distortions imposed by the deduction of healthcare premiums from the taxable portion of income. Such a plan would provide a tax credit of $2,500 per person and $5,000 per couple to help Americans finance their healthcare.

"The universal tax credit would provide a powerful incentive" to purchase insurance, Miller said, without displacing employer-sponsored insurance if firms opt to offer plans. "We shouldn't be afraid to level the playing field," he said, though not with mandatory enrollment and "cookie-cutter plans."

"We also need to rely on competition" and make insurance available "across state lines," Miller urged. He described the McCain strategy as "not something with one grand national plan" but a system delivering "better value" without seeking the chimera of "unrealistic perfection."

In response, the audience voted that less than half, 45%, see McCain's plan as feasible, an identical number indicating that such a plan would contain costs.

Representing Clinton, Chris Jennings of the consulting firm Jennings Policy Strategies (Washington) described her plan as "absolutely the only proposal up here" offering the prospect of universal access to care.

Cooper is wrong, he said, about a purported lack of support for mandatory health insurance enrollment in Congress, citing a proposal by Sen. Ron Wyden (D-Oregon) as an indicator that bipartisan support does exist.

"The reason we want everyone in the system is to make the system work rationally," Jennings said, calling McCain's approach "the most disruptive policy" that would "certainly not have a significant benefit for the majority of Americans." And the McCain plan, he said, "would undermine the ability of sicker Americans" to get access.

Clinton's plan "ensures choices of coverage," Jennings said, including an expansion of Federal Employee Health Benefits. Clinton's approach, he said, "makes premiums more predictable and more affordable."

He said her plan cuts down on cost shift, shores up "the safety net" of Medicare and Medicaid, and "promotes shared responsibility among pharmaceutical manufacturers" by forcing them to market their products with "fair prices."

After Jennings' talk, the audience rated the Clinton plan as feasible by 54%, with 51% voting that they thought that such a plan would control costs.

However, in an interesting insight into voter psychology, an immediate revote on Obama's plan showed that the audience gave the Obama proposal much better numbers on feasibility, up from 27% to 50%, and a more modest rise on cost control ability, from 50% to 54%.