Where do Obama and Clinton REALLY stand on healthcare?

February 11, 2008 7:00 AM

What are the main differences between Obama and Clinton's healthcare proposals?

Everything I've read and heard seems to basically state that Hillary leans toward a federal-type plan while Obama doesn't. In reading both of their proposals, I'm hard pressed to see many differences in where they stand. This blog post inspired this question. As an aside, it was an interesting read.

posted by KevinSkomsvold to health & fitness (38 answers total)

My (extremely basic) understanding is that Hillary wants to make health care required for a large part of the population, the idea being that if we insure everybody then costs will go down as people receive better preemptive care. Obama's plan is that he wants to heavily subsidize health care coverage for the segment of the population who are not insured, the idea being that most people want health care, so if we make it affordable for everybody then everybody will want to get it. Both plans allow for people with existing private coverage to keep it if they desire.

I guess on a really basic level you could boil it down to Hillary's plan being more regulatory (we're going to give everybody health care) and Obama's being more free market (if it's affordable for everybody, everybody will get it).

If my understanding is incorrect please feel free to edify me.
posted by baphomet at 7:06 AM on February 11, 2008

Their plans are very similar. They are both proposing a way to make health insurance cheaper and available to all Americans. Neither of their plans would provide healthcare for free to everyone. The main difference is that Clinton's plan makes health insurance mandatory, while Obama's makes having health insurance option for adults who choose not to pay for it.

This article has a relatively short analysis of the differences.
posted by burnmp3s at 7:06 AM on February 11, 2008

I'm eager to hear some responses on this as well. Re: that blog post you linked, what it doesn't address is the enormous population difference between the US and Canada and how what works up north can be scaled up 9-10x.
posted by gsh at 7:07 AM on February 11, 2008

Clinton's plan mandates that everyone purchase health insurance. Think car insurance: you're required to have it. The plan provides subsidies with the intention of making this an affordable proposition.

Obama's plan does not include mandates.

From what I've read, most economists think that the mandates are the way to go.

On the other hand, based on the situation that is unfolding in Massachusetts, mandates may not be a realistic real-world solution. Telling a family of four with an income of $65,000 that they need to start spending $12,000/year on health insurance may be good economic and public health policy, but it also makes people very very angry. I live in Mass and I supported the law, but I'm worried that there is a backlash brewing. Unless we can get costs under control to a degree that we have not yet done, I don't believe the mandates will survive.
posted by alms at 7:08 AM on February 11, 2008 [2 favorites]

burnmp3s - Yes, very similar and that is why I'm inclined to believe it is a non-issue in most respects. Thanks for the link as well.
posted by KevinSkomsvold at 7:10 AM on February 11, 2008

From what I've read, most economists think that the mandates are the way to go.

Ah, there we go! I'd be interested in why they think this. If you have any links, that'd be awesome.
posted by KevinSkomsvold at 7:13 AM on February 11, 2008

Ah, there we go! I'd be interested in why they think this. If you have any links, that'd be awesome.

Paul Krugman had a column comparing their health care proposals in last week's NYT (though he's been pro-Clinton in general lately, so take it for what you feel it's worth). I haven't taken the time to look for the Jonathan Gruber paper that Krugman cites, but maybe that'll give you the hard numbers you want.
posted by Prospero at 7:29 AM on February 11, 2008

Some economists disagree on mandates:

Avoiding the mandate keeps the private insurance market relatively "clean," as it were. Mandating private insurance means that the government has to regulate the content of that coverage and that private insurance will likely become more cumbersome and more contested and more expensive for everyone.
posted by drezdn at 7:32 AM on February 11, 2008

Obama's plan does not include mandates.

Not entirely true, coverage for children would be mandatory.
posted by teleskiving at 7:36 AM on February 11, 2008

I live in a state with subsidized health care (and am a recipient of such health care) and above a state with mandated health care. If you're interested in how variants on these ideas work out in smaller petri dishes you could look at Vermont's current system [subsidized, not mandatory] and Massachusetts's [mandatory, a little subsidized]. MA will probably wind up also having to subsidize people for exactly the reason alms suggests, so probably some hybrid solution is going to be the most workable.
posted by jessamyn at 7:39 AM on February 11, 2008

Everyone has been largely correct so far. The reason why I like Obama's plan is because I can envision it getting passed. Clinton's plan has mandates. I grew up in Indiana. I know how that word translates to a lot of Americans - SOCIALISM. Obama's plan has the benefit of appearing to be about personal choice and the free market. So, the people may grumble, but if they see it as something they have the option to choose for themselves, it makes it much more appealing. Even if Clinton did muscle through her plan, it would be like a new Roe v. Wade. You would get Republican congressmen and Senators elected to Congress who will run solely on the platform of reversing socialism and restoring freedom back to the 'Merican people.
posted by billysumday at 7:45 AM on February 11, 2008 [1 favorite]

The logic for mandates states this: if only the sick get healthcare, then costs will be driven up. Why do well people want health insurance now? Because if they try to get it when they're sick, they might be denied due to a preexisting condition. But in both plans, denying people due to preexisting will be made illegal. Therefore, how will Obama's plan stop me when I only choose to buy healthcare when I get cancer? When asked, Obama has stated "If people are gaming the system, there are ways we can address that. By, for example, making them pay some of the back premiums for not having gotten it in the first place." Some would call this a back door mandate.

Obama's plan does mandate for children though. And the thought of mandated healthcare leading to a bill showing up on April 15th for your mandatory health insurance scares some people. And makes me think of commercials on late-night tv for "1-800-Safe Health: Minimum Health Coverage Required by the Law." (Do other states have those terrible ads for Safe Auto that pretty much turn auto insurance into a bribe you have to pay off so police don't arrest you?)
posted by ALongDecember at 7:45 AM on February 11, 2008

It should be stressed that they are REALLY similar if both plans unfolded in the way their supporters predict. While Obama's doesn't require adults to have it (children would be covered), his idea is that he's making it so affordable (by way of subsidies) everyone who needs it will buy it. He's struggled in debates to articulate this (or maybe just to convince people it's true), but he believes he'll get near-universal coverage by making it so affordable, and that most of those opting out would be those who can afford to pay as they go no matter what.

That's what he figures, at least. Why do this and not a mandate like Clinton's? One reason is political expediancy (he's more likely to get the Right on board ). The other is that he's not making rich people get insurance they don't want or need (but he's still getting their taxes, which will help go toward subsidies).

What we really need are a couple good predictions (based on what, I don't know) by economists for how many poor people will still opt out under Obama's plan. We then need an idea of how many of those people will fall victim to bad health problems later on, and what those costs are. Then we'll know what the differences in effect between Obama's and Clinton's plans will actually be (Obama wins if not that many poor people opt out and rich people don't mind as much).
posted by aswego at 7:52 AM on February 11, 2008

The reason why I like Obama's plan is because I can envision it getting passed.

This is important to remember. Obama and Clinton are running for president, not for dictator. If one is elected, the proposals on his or her campaign web site do not automatically become law. So the viability of these proposals in Congress is a very important factor to consider when you're considering which one you prefer.
posted by Dec One at 8:15 AM on February 11, 2008 [1 favorite]

I haven't had time to study this closely, but it does seem to me that the heavier the subsidies on premium costs, the less problematic the adverse selection problem because. The reason you don't want healthy people opting out is because you want everyone paying into the system so that you can spread the costs around as much as possible. But if the people opting out weren't going to pay that much into the system in the first place because of subsidies, then it seems like less of a problem.
posted by yarrow at 8:16 AM on February 11, 2008

because->becomes. Arg.
posted by yarrow at 8:16 AM on February 11, 2008

A discussion with one of the economists who helped design Obama's plan.
posted by shothotbot at 8:19 AM on February 11, 2008

Here's an OK survey of recent Democratic opinion on the differences, focusing mostly on the horserace aspect, but linking to smarter stuff.

Ezra Klein is one of the leading left-leaning bloggers on health care issues; here he criticizes Obama's advertising on the issue. Surely somewhere he goes into the merits of the two plans, and I believe he too favors Clinton's, but I unfortunately can't find it in a minute of Googling.
posted by ibmcginty at 8:27 AM on February 11, 2008

Neither of these plans would get implemented like they are currently described, since they would be rewritten during conference with Democratic leaders and certainly changed during debates and private negotiation in Congress.
posted by demiurge at 8:32 AM on February 11, 2008 [1 favorite]

This is a Clinton/Obama side-by-side on their health care plans.*

Data point: I work for the non-profit that runs this website, but I have no hand in creating content, or on the policy side of things.
posted by rtha at 8:38 AM on February 11, 2008 [1 favorite]

This is an interesting take on the mandate issue.
posted by designbot at 8:42 AM on February 11, 2008

More from the same author.
posted by designbot at 8:48 AM on February 11, 2008

I live in Massachusetts (which has mandated health insurance). I signed up for the Commonwealth's newly created privately run insurance program, Commonwealth Choice. In effect, the quasi-governmental but entirely private for-profit company, Commonwealth Choice, plays the middle men between you and your insurance company (Blue Cross Blue Shield, Tufts, Harvard Pilgrim, etc). To briefly summarize, the plan I signed up for was entirely misrepresented by Commonwealth Choice and Commonwealth Choice was a bureaucratic nightmare of bad service. Blue Cross offered virtually the same plan for the same price outside of the Commonwealth Choice umbrella.

I've also lived in Europe with real universal healthcare. Mandating private health insurance is not the same thing as delivering quality universal coverage.

A couple links to consider:

Don't assume that mandates are cheaper - via Marginal Revolution with links to other commentators

Healthcare in France and Germany - via The Institute for the Study of Civil Society. Full link to 2001 report at the bottom of the page.
posted by McGuillicuddy at 8:53 AM on February 11, 2008

One hanging issue on Obama's model is the gap between the rhetoric -- 'everyone who wants insurance and can't afford it will be able to get it' -- and the reality. That's to say, it's hard to get from the current premiums of the federal employee plan to a premium level that doesn't need thinking about for sign-on without massive subsidies.

If you're going to have a level of subsidy that puts premiums within reach, whether as a FICA-style deduction or a fixed monthly cost, there's a good argument to make it universal as a matter of principle and policy rather than a welcome consequence. Universality-in-principle is harder to roll back, and also potentially provides more space for cost-cutting. There's also the issue of 'adverse selection', which, as Krugman and others have noted, sets up the prospect of an imbalanced risk pool: the sick may sign up, while the healthy opt out; if the opters-out get sick, they may delay treatment until their conditions require more expensive care. One pragmatic benefit of universality is getting people into the doctor's office: early treatment is usually cheaper treatment.

The devil's really in the details, and there's really not much between the two candidates, particularly when you think of the mechanics of getting any plan passed. There's an argument to be made that Clinton's universal model is a harder sell, and that Obama's electoral coat-tails might bring additional Senate seats and improve the chances of a more ambitious bill coming out.

Ezra Klein's blog is a great place to start: he links out to other healthcare wonk types, and has a fairly robust discussion on the arcane stuff in comments.
posted by holgate at 9:04 AM on February 11, 2008

Here is a criticism (by Mark Kleiman of UCLA School of Public Affairs) of Krugman's criticism of Obama's plan. The study that Krugman depends on to determine the cost of not having mandates is essentially BS.
posted by goethean at 9:55 AM on February 11, 2008

Paul Krugman's analysis of their positions, TPM's Dean Baker's response to Krugman, and Krugman's response to Baker.

Prospero posted the Krugman piece earlier, but I didn't know if anyone was aware of the back-and-forth.
FWIW, I'm an Obama sympathizer, but I think Krugman's absolutely correct with his criticism of Obama's health plan.
posted by tuxster at 9:58 AM on February 11, 2008

Another way that the two healthcare plans differ that I haven't seen mentioned above is mentioned in this post on the blog Health Beat. Obama's plan does have mandates, but for companies rather than individuals (sometimes this is called "play or pay"). As the author points out, this is something that is more likely to harm workers at low-wage firms that aren't currently offering health insurance (the majority of whom are low-income people). Mandates on individuals, on the other hand, fall most heavily on those who make too much money to qualify for subsidies but for whatever reason don't want to pay full price for health insurance. As some people pointed out above, it may be that this second group is mostly middle-income people who don't really make enough to pay full price for health insurance. However, it may also be that this group includes a fair number of people who could afford health insurance, but because they are young and in good health don't want to pay for insurance. It sucks to be an unmarried 25-year-old with no kids paying $300 a month for insurance if you barely ever go to the doctor, but if we don't get all of those people into the market to subsidize the cost, insurance prices will be really high.

Personally, I don't particularly buy the argument that we can make all individual insurance guaranteed-issue (that is, requiring insurance companies to let anyone buy a policy who asks) without mandating coverage. It's kind of like telling people that they don't have to participate in Social Security unless they want to--who would choose to participate while young and not needing it rather than waiting until 10 or 15 years before retirement, when all of your highest-earning years that determine your Social Security check happen anyway?

If you buy the argument that we'll have to move to a system where everyone has coverage (whether single-payer or mandated through private insurance) eventually, then the issue of Obama's ads criticizing Hillary for the mandate become much more relevant, I think. It will be significantly harder for Obama to push through anything that even suggests a mandate when the opposition can throw his own words criticizing mandates in his face.
posted by iminurmefi at 10:19 AM on February 11, 2008

One really crucial difference between Obama and Clinton's plans that I haven't seen much discussion of here or elsewhere is that Obama's plan, unlike Clinton's, also establishes a new national health care plan as an alternative to the plans offered by private health-care plan providers.

Clinton's proposal doesn't appear to offer any comprehensive public health-care plan as an alternative to the private health care plan providers, while Obama's plan does offer a new option (his own statements on this issue suggest he would establish a national plan with benefits like those currently enjoyed by congress). I'm not sure why this difference, which to me seems pretty stark, doesn't come up more often in discussions about the differences in the two-candidates' proposals. It's a pretty major difference. Now I may be mistaken in my understanding that Clinton's plan doesn't offer something analogous to Obama's proposed national plan, but I'm confident about what Obama's proposing. Here's his site's official policy statement. I've highlighted the relevant parts:

Obama's Plan to Cover Uninsured Americans: Obama will make available a new national health plan to all Americans, including the self-employed and small businesses, to buy affordable health coverage that is similar to the plan available to members of Congress. The Obama plan will have the following features:

1. Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions.

2. Comprehensive benefits. The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential medical services, including preventive, maternity and mental health care.

3. Affordable premiums, co-pays and deductibles.

4. Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.

The key differences are as follows: Clinton's plan requires Americans to get private health care coverage through their employers or through private providers, and then establishes a new system for regulating these private health care plan providers and to bring down the costs of such plans (with end-of-the-year tax breaks to ease the burden on all the people who now find themselves required to purchase a private plan). Obama's plan, meanwhile, establishes a new subsidized public health care plan meant to serve as an alternative to the plans currently available through private providers.

In a nutshell, Clinton's plan is to make private health care mandatory and easier to afford through regulation, Obama's plan is to make private health care easier to afford and more readily available and to offer a publicly-subsidized alternative to the private health care plans that would be available to anyone seeking a health-care plan.
posted by saulgoodman at 11:13 AM on February 11, 2008 [2 favorites]

Note that these are just that, plans. As others have pointed out, they will be implemented with jockeying from both houses and *lobbyists*. Those variables mean that whatever someones plans are they will be watered down.
posted by lalochezia at 11:31 AM on February 11, 2008

Another point that is worth discussing is the mode of payment for those who can't afford to pay complete costs out of pocket. Obama calls for means-tested subsidies while Clinton offers refundable tax credits. For Obama's plan that would imply, to me, that the government will pay whatever portion of your premium exceeds a set percentage of your income, and unless I'm misunderstanding what a refundable tax credit is, Clinton's plan would see premiums above $X paid in 2010 returned with a family's IRS refund in 2011.

If I'm misunderstanding, I hope someone explains so. But if not, it seems clear which is a winning proposal for working class citizens who are currently seeing the price of coverage for their entire family as too huge a chunk of their income to outlay without assistance. If you're struggling to pay the bills now, knowing that you have to wait until the next spring to get help back is cold comfort compared to a bill that's automatically lower because there's a subsidy built in.
posted by Dreama at 12:29 PM on February 11, 2008

Saulgoodman, I'm a big Obama supporter, but I believe (ok my girlfriend pointed out) that you're incorrect about Hilary's plan not creating a national public health care system.

From here:
The Same Choice of Health Plan Options that Members of Congress Receive: Americans can keep their existing coverage or access the same menu of quality private insurance options that their Members of Congress receive through a new Health Choices Menu, established without any new bureaucracy as part of the Federal Employee Health Benefit Program (FEHBP). In addition to the broad array of private options that Americans can choose from, they will be offered the choice of a public plan option similar to Medicare.

Nthing the winner's plan being watered down by congress.
posted by zazerr at 2:36 PM on February 11, 2008

Actually, from the Clinton site, there is this bit:

In addition to the broad array of private options that Americans can choose from, they will be offered the choice of a public plan option similar to Medicare.

...Which does suggest the Clinton plan also at least pays lip-service to establishing a public health care provider option (although she's put a lot less emphasis on that aspect of her proposal, and it almost seems like an afterthought to me--my guess is that any public plan under Clinton will be so inadequate, most users will opt for one of the private plans).

The real differences, then, between the two plans are that Obama's places more emphasis on establishing a public health care plan and doesn't mandate universal enrollment, while Clinton's plan mandates universal enrollment (how exactly that part of the plan gets enforced, beats me) but puts a much stronger emphasis on working with private health care providers. It's also not clear whether, apart from end-of-year tax breaks, the Clinton plan offers any relief for out-of-pocket enrollment costs. The income-based subsidies discussed in her plan are tax rebates.

From the Obama site:

The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible. Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency.

The emphasis in Obama's plan is on establishing a robust public health care system and offering it as a competitor to the private provider plans. Clinton's plan, on the other hand, is much more private health care provider centric.
posted by saulgoodman at 4:52 PM on February 11, 2008

Which does suggest the Clinton plan also at least pays lip-service to establishing a public health care provider option (although she's put a lot less emphasis on that aspect of her proposal, and it almost seems like an afterthought to me--my guess is that any public plan under Clinton will be so inadequate, most users will opt for one of the private plans).

Um, that's complete crap. Obama originally didn't even make his public option available to everyone, only to people who couldn't get insurance otherwise (the unemployed, self-employed, and those whose employers didn't offer health insurance) but quietly reversed himself a few weeks later after opposition, just as he's now quietly reversing himself on the mandate issue.

The emphasis in Obama's plan is on establishing a robust public health care system and offering it as a competitor to the private provider plans. Clinton's plan, on the other hand, is much more private health care provider centric.

Again, you have it backwards. Obama requires that all the private plans offered in his big exchange be at least as generous as the public plan. In other words, the public plan will be the worst one offered on the exchange. Hillary, on the other hand, does the opposite: she guarantees that her public plan will have benefits at least equal to those offered by private companies under the FEHBP. If Obama's plan is enacted, the HMOs will have a strong incentive during the negotiations and after to lobby for making the public plan as skimpy as possible, to reduce the benefits that they're required to offer on the exchange.
posted by gsteff at 7:55 PM on February 11, 2008

Edge of the American West is collecting links to substantive analytical blog posts about how Clinton and Obama differ (on all issues, not just health care). Might be of interest.
posted by LobsterMitten at 8:37 PM on February 11, 2008

Um, that's complete crap.

Thanks for that shining moment of brilliance! I'll have to revisit all my original assumptions and reexamine my whole argument now. Good work!

Again, you have it backwards. Obama requires that all the private plans offered in his big exchange be at least as generous as the public plan. In other words, the public plan will be the worst one offered on the exchange. Hillary, on the other hand, does the opposite: she guarantees that her public plan will have benefits at least equal to those offered by private companies under the FEHBP.

More of that really helpful tone! But I'm afraid, this time, you've got it completely orthogonal!

Your last point is pretty much moot. From my POV, the point in Obama's proposal is to emphasize the role of the public plan as a competitor to the private plans. And despite what you say, I can't find anything in Clinton's proposal that guarantees benefits at least equal to those offered by the private plans. Her proposal does claim the public plan will be comparable to those other plans, but with limited maternity coverage and so on.

Obama originally didn't even make his public option available to everyone, only to people who couldn't get insurance otherwise

Well, while we're making spurious accusations about candidates changing their positions (first, this claim to my knowledge is not accurate--as long as I've been following the campaigns, Obama's official proposal outlined on his campaign site always provided the public plan as an option, for any Americans who wanted it), I don't recall the Clinton campaign making a point about establishing a public health care plan provider system at all until very recently, other than proposing to establish a system (Healthy Choices Plan) for brokering plans with private health care plan providers. What's striking to me is the sudden change in emphasis on a public plan.

But at the risk of getting bogged down in this kind of toxic, he-said-she-said crap, let's get down to the bare facts.

Ultimately, these are very complicated issues and there are no simple answers. And despite what either candidate may say or sincerely hope, political realities may prevent them from ever really even getting their proposals up and running (I seriously doubt a plan of some kind won't eventually be adopted, though, considering the importance of this issue).

The best way to decide where the candidates stand is to compare their official campaign statements on the issues. Clinton's plan is discussed here. Obama's is discussed here.

The major differences that aren't in dispute are these: Clinton's plan will require mandatory participation and the financial burden to American's enrolling in the new plan will be offset by end-of-the-year tax rebates. Obama's plan will be available to all American's on a voluntary basis. Both plans will allow you to continue any private coverage you currently have as an individual or through your employer should you so desire, and both will provide additional measures to reduce health care costs all around.
posted by saulgoodman at 8:02 AM on February 12, 2008 [1 favorite]

Today (Tuesday) on Fresh Air they'll be talking about candidates' health care plans.
posted by rtha at 8:43 AM on February 12, 2008

[comment removed - SERIOUSLY take it to email or MeTa if you can't answer this question without calling someone names.]
posted by jessamyn at 11:09 AM on February 12, 2008

And despite what you say, I can't find anything in Clinton's proposal that guarantees benefits at least equal to those offered by the private plans. Her proposal does claim the public plan will be comparable to those other plans, but with limited maternity coverage and so on.

From page 6 of the official pdf of her full plan:

In addition to the array of private insurance choices offered, the Health Choices Menu will also provide Americans with a choice of a public plan option, which could be modeled on the traditional Medicare program, but would cover the same benefits as guaranteed in private plan options in the Health Choices Menu without creating a new bureaucracy.

Well, while we're making spurious accusations about candidates changing their positions (first, this claim to my knowledge is not accurate--as long as I've been following the campaigns, Obama's official proposal outlined on his campaign site always provided the public plan as an option, for any Americans who wanted it)

From the NYTimes article covering the unveiling of his plan:

Mr. Obama would create a public plan for individuals who cannot obtain group coverage through their employers or the existing government programs, like Medicaid or the State Children's Health Insurance Program.

From his website on July 13, 2007, via the Internet Archive:

Obama will create a new national health plan to allow individuals without access to affordable insurance coverage to buy coverage similar to that available to members of Congress.

I don't recall the Clinton campaign making a point about establishing a public health care plan provider system at all until very recently, other than proposing to establish a system (Healthy Choices Plan) for brokering plans with private health care plan providers.

From the NYTimes article covering the unveiling of her plan (second graf, no less):

Under her plan, people could keep their existing coverage or pick new choices, such as an expanded version of the insurance available to federal employees or a new, Medicare-style public plan that would cost people less.

From my POV, the point in Obama's proposal is to emphasize the role of the public plan as a competitor to the private plans.

Yes, because you're an Obama partisan. I support Obama too, but accept the view of virtually every liberal health care policy expert I've read that his plan was the worst of the three (the only exception that comes to mind is Robert Reich). As I said before, Obama originally intended for the public plan to be a backup for those with no other options, and he eventually quietly reversed himself under pressure. Even today, he guarantees that the public plan will be the worst one offered on the exchange, while Clinton guarantees that hers will be as good as or better than the menu offered under the FEHBP.
posted by gsteff at 12:21 PM on February 12, 2008