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In fairness, whose plan is better?

The Baltimore Sun

The election is less than a week away. Health care remains a key issue for most Americans, with the declining economy serving to underscore how important it is that the next president get health care right. Considerable ink and blog space have been devoted to explicating the details and expected outcomes of Sen. Barack Obama's and Sen. John McCain's health care plans. Armed with analyses from health economists, both campaigns are peppering last-minute speeches and ads with specific figures about how much money their health care plans would save you and how much their plans would cost.

Yet we would all be wise to take these figures with a large grain of salt. Health economists are the first to say that the assumptions they are using to generate the numbers are open to serious question.

Despite such uncertainties, Americans need to know whom to trust to meet the challenge of health care reform. There are real differences between the candidates, but in this case, it is far safer for voters to make decisions based on the candidates' values rather than the candidates' facts. Mr. McCain's and Mr. Obama's health plans are based on very different moral visions of what makes a health care system fair, and this difference offers voters a real basis for choice.

What Mr. McCain sees as unfair about our current system is how the costs of health care are financed. Some Americans pay the full freight of their health insurance and medical care, but many others do not. These include not only people eligible for Medicare or Medicaid but also those of us fortunate to get health insurance through our employers. Americans who have workplace health insurance get a tax break that subsidizes the costs of insurance, while other Americans without this workplace benefit get no federal help with these costs. Mr. McCain would change the tax code to ensure that all Americans enjoy the same package of tax incentives for health insurance. The centerpiece of his health plan eliminates tax breaks for workplace insurance and instead gives all Americans the same tax credit for health insurance: $2,500 for individuals and $5,000 for families.

Mr. McCain is right. There is no morally defensible reason why some Americans get federal assistance with health care costs and others, including many who are uninsured or underinsured, do not. The way we finance health care in this country is fundamentally unfair.

But unfairness in financing is only a part of what is morally wrong with our health care system. There are more immediate and egregious forms of unfairness at stake, and these concerns are at the heart of Mr. Obama's plan.

What Mr. Obama sees as most unfair about the system are the profound disadvantages that people without access to adequate health care experience, not only with regard to health but across multiple dimensions of well-being, including peace of mind, personal and economic security and the self-respect that comes from being able to plan for and meet the needs of one's family. As a consequence, the central feature of the Obama health plan is a commitment to the goal of (near) universal health insurance, with decent coverage for all. Instead of eliminating tax breaks for workplace insurance, employers would be required or subsidized (depending on their size) to assist with health care costs. Americans without workplace insurance would have expanded options to secure health insurance through a variety of private group plans and a new public plan. Although health insurance would be required only for children, the aim is to get as many people possible insured.

Mr. Obama's plans would not fix the unfairness in financing and the tax code that Mr. McCain correctly identifies. However, by preserving the workplace system, unfair though it is, Mr. Obama is taking fewer risks with what is, for many of us, more important: making sure that all Americans have access to decent health care.

Some things can and should wait till the economy improves; health care reform is not one of them. Perhaps nowhere more than in health care, we face a real choice in November. The choice is not merely between two different health plans, but even more so between two very different understandings of what is unfair about our current system, and two very different understandings of what matters most about health care. We can spend the remaining days of this campaign trying to make sense of the soft numbers and contested projections being used to describe the Obama and McCain health plans, or we can just remember that when it comes to fairness, Mr. McCain gets it half right, but Mr. Obama gets it more right.

Ruth R. Faden, director of the Johns Hopkins Berman Institute of Bioethics, and Madison Powersdirector of the Kennedy Institute of Ethics at Georgetown University, are the authors of "Social Justice: The Moral Foundations of Public Health and Health Policy."

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