Let's Try This Again: Questions for the Candidates on Reforming Health Care

US President Barack Obama (R) and Republican challenger Mitt Romney shake hands following their first debate at the Universit
US President Barack Obama (R) and Republican challenger Mitt Romney shake hands following their first debate at the University of Denver in Denver, Colorado, October 3, 2012. After hundreds of campaign stops, $500 million in mostly negative ads and countless tit-for-tat attacks, Obama and Romney went head-to-head in their debut debate. AFP PHOTO / Nicholas KAMM (Photo credit should read NICHOLAS KAMM/AFP/GettyImages)

The presidential and vice presidential candidates spent a lot of time on health care in their last debates -- for all the good it did the voters. The comforting generalities and sleep-inducing statistics may have helped the voters get a sense of personalities. When it comes to actually sorting out practical options on health care, however, we're concerned the public's no better off than it was a month ago.

Fortunately, there are two more shots at this, at the presidential debates coming up this week and next, and the public deserves better answers than they're getting.

The country faces a tough dilemma. We can't afford to do what most Americans would like to do -- keep the system we have, expand it to cover more people, but shield individual patients from the virtually all of the rising costs. The federal government can't afford it, states can't afford it, and employers can't afford it either. With the spiraling cost increases we've seen over the last few decades, it's just not possible.

According to the Congressional Budget Office, health care costs more than tripled between 1965 and 1985, and then nearly tripled again in the next 20 years, reaching a total of $1.9 trillion dollars in 2005. Just for comparison's sake, the combined cost of the wars in Iraq and Afghanistan -- from their inception up to now -- is just over a trillion dollars.

Unfortunately, this election season, too many candidates are dodging this reality and perpetuating the idea that we can control costs without changing what we do. Candidates up and down the line are using proposed changes in Medicare (either the Obama cost-cutting or the Romney-Ryan voucher idea) as a cudgel to hammer their opponents. Elect me, they suggest, and Medicare as we know and love it can remain just the same as it's always been. Republicans revile the Obama health care legislation, but they haven't offered any real alternative. We can count on the press to keep asking questions about Medicare and Obamacare, and we can no doubt count on most candidates to supply pre-packaged answers that dodge the vital issues. So, in this issue of The Question Project -- our election blogs attempting to raise some more fundamental, probing issues in the campaign -- we're offering up these questions for President Obama and Governor Romney. Many of them apply to candidates for Congress and state and local office as well.

  • Here's an issue neither presidential candidate bothers to address: The Congressional Budget Office has concluded that the "growth in real spending on health care was principally the result of the emergence of new medical technologies and services and their adoption and widespread diffusion" by the U.S. health care system. But better tools for diagnosis and better procedures and drugs for treatment are precisely what many Americans value most about our system. To what degree do you believe that advancing technology has improved care? How would your ideas affect spending in this area?
  • Governor Romney, you've argued that more competition in the system could play an important role in stabilizing costs. But health insurance companies have competed for business among employers for years. Businesses have every incentive to keep costs down, and bargain as hard as they can, and yet health insurance costs have continued to spiral. Why hasn't competition in the business-to-business market been more effective? Why do you think your ideas would be more successful in this regard?
  • President Obama, you've said that your plan "would change incentives so that providers will give patients the best care, not just the most expensive care, which will mean big savings over time." But we've seen numerous attempts to change incentives in health care, "managed care" and HMOs, for example. Not only were they not popular, they didn't make much of a dent in rising health costs. Why would your idea for "accountable care organizations" work better?
  • The vast majority of health care costs come from a small number of very sick patients who have catastrophic injuries or diseases or suffer from multiple serious and chronic health problems. Tell us why you believe your ideas to control costs will accomplish their goals in a humane and conscionable way? How would the ideas you've put forward affect people with very serious illnesses?
  • There's been a lot of discussion about the power of patients "shopping around" for both insurance and health care. Realistically, however, doctors, not patients, make most of the decisions about tests, drugs, and procedures. Patients have a lot more information than they used to, but many patients still either don't have an incentive to question the doctor or don't feel they have the expertise to do so. In addition, a health insurance plan is a pretty complicated financial instrument -- and the mortgage crisis showed that the public can have problems dealing with complex financial issues. In your view, how do we make individuals the savvy health consumers they need to be? And what about the doctors -- how would your ideas insure that doctors are focusing on doing the best for their patients, but in cost-effective and ethical way?
  • Many experts believe that Americans would be healthier, and the country would be more successful in controlling rising costs if we could find effective ways to reduce smoking, obesity, substance abuse, and accidents? How much do you believe these factors contribute to rising health care costs, and do you see a role for government in this area? If so, do you think government's role should be primarily educational or are there other steps we should take?

We've just scratched the surface on what we'd like to hear from the candidates on health care, and we'd welcome your additions to our list. To use a tired, old pun, most Americans are worried sick about what is or will happen to the American health care system. So far, they deserve a more candid and less manipulative conversation than they've got.