Campaign 2008

The US presidential candidates are focused on the economy. But both have put statements about healthcare and IT on their websites, and both have given other clues about what an Obama or a McCain presidency might mean for healthcare IT in the USA. Neil Versel reports.

Whatever other failings he may have, US President George W Bush has succeeded in putting health information technology on the national agenda. How the two men vying to occupy the White House for the next four years intend to promote e-health is only slowly coming into focus.

Neither of the major-party presidential campaigns responded to requests to expand on their brief, generalised statements about health IT, but clues are out there.

War of words online

On his campaign website, Democrat Barack Obama offers the following: “Obama will invest $10 billion (£5.6 billion) a year over the next five years to move the US healthcare system to broad adoption of standards-based electronic health information systems, including electronic health records.

“He will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen. Obama will ensure that these systems are developed in coordination with providers and frontline workers, including those in rural and underserved areas. Obama will ensure that patients’ privacy is protected.”

The Republican candidate, John McCain, says even less on his campaign site: “We should promote the rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines." In the US, physician licensing is done at the state level, and each state’s laws are different with regard to who may provide medical care to residents.

McCain also calls for greater transparency to encourage consumerism. “We must make public more information on treatment options and doctor records, and require transparency regarding medical outcomes, quality of care, costs and prices. We must also facilitate the development of national standards for measuring and recording treatments and outcomes,” his site says.

Both candidates frame the IT debate in terms of cost savings rather than quality improvements. In fact, McCain has run a television advert in which he personally says: "The problem with healthcare in America is not the quality of healthcare, it’s the availability and the affordability" – numerous academic studies to the contrary notwithstanding.

Heavy-weight analysis

The Henry J Kaiser Family Foundation has been collecting candidates’ statements and providing analysis at www.health08.org. The organisation says both presidential nominees favour greater use of technology to measure and report outcomes, though they take slightly different approaches.

According to the foundation, Obama believes that IT should be a prerequisite for participating in government-sponsored health programmes, and he would require insurance companies to collect, analyse and report quality data for underserved populations.

McCain, the Kaiser Foundation says, wants financial incentives for proper diagnosis, prevention and coordination of care, and would withhold reimbursements for preventable medical errors or mismanagement of patients enrolled in the Medicare programme for seniors or the Medicaid programme for the indigent.

He would set national standards for outcomes measurement and use IT to promote best practices. He also advocates greater use of telemedicine for caring for rural and inner-city populations.

In an article published last month on the website of policy journal Health Affairs, University of Pennsylvania health economist Mark Pauly said the two candidates’ plans are similar in that they both tout IT, quality-based reimbursement and preventive care as means of saving money and improving outcomes. But, he says, the savings McCain and Obama envision are less than the current rate of healthcare inflation.

“The main problem is that these are ‘if only’ savings, which can be achieved ‘if only’ certain events would occur, such as physicians’ being willing to adopt health IT, consumers’ being willing to accept changes in diet and exercise, the timely receipt of preventive care, or full trust in primary care doctors who are custodians of a medical home,” Pauly wrote.

And good old fashioned point scoring

Health Affairs also ran critiques of each plan by supporters of the other candidate. McCain backers Joe Antos, Gail Wilensky and Hanns Kuttner rapped the Obama proposal to allow some of the estimated 47 million Americans without health insurance to buy into coverage pools offered to government employees.

“It greatly increases federal regulation of private insurance, including what benefits must be offered by all insurance plans, but it does not address core economic incentives that drive healthcare spending,” the trio wrote. They said the Obama plan fails to address the current perverse incentives in health insurance that encourage high utilisation of services rather than quality.

David Cutler, an Obama adviser, says McCain misses the point of healthcare reform, as evidenced by the advert. “If the concern about medical spending is so great, why not put up federal money for health information technology? Why not stress prevention more, instead of encouraging people to be in catastrophic [insurance] plans, where we know prevention suffers?” he asks. “If costs are a problem, attack the cost problem!”

However, with the US economy seemingly on a downward path and government debt soaring to record levels, new federal funding might be hard to come by. In the four-plus years since Bush began advocating strongly for e-health, the US Congress has failed to pass any large-scale legislation to promote IT in healthcare, save for an e-prescribing incentive programme that takes effect in 2009, suggesting that lawmakers do not fully understand the issues.

It is worth noting that both McCain and Obama are senators, and the winner will be the first sitting legislator to be elected president since John F Kennedy in 1960.