The Lancet analisa as possíveis mudanças no "sistema" de saúde americano, com Obama ou McCain vencendo a eleição em novembro. No entanto, há dois pontos importantes: a questão econômica será mais importante do que o Iraque e, também da saúde. Fato impensável há um ano; o poder legistlativo controla o orçamento e, os democratas já está há 18 meses com maioria nas duas casas.
With John McCain long the last man standing among the Republican candidates, and Hillary Clinton having just stepped aside for Barack Obama, the long drawn out campaign for the US presidential nomination now takes a new path. The electorate can turn its attention to the issues, and not just the personalities, at hand. For many Americans, especially the large number of uninsured and underinsured, the most pressing domestic concern is health care. So where do the presumptive nominees stand on this issue? The first fault line between them is predictable: in traditional Republican style, McCain believes in market-based solutions to health-care reform. He would not dismantle the employer-based insurance system, but would provide tax credits to make it more affordable. McCain claims that he would promote competition among insurance companies by allowing the selling of policies across state lines; whether this step would be enough to create real competition is doubtful. Obama's plan is also predictably Democratic, although it is not as radical as the single-payer plan favoured by the most liberal wing of the party. His plan instead is a compromise of sorts: universal coverage would be achieved through retention of private insurance along with the expansion of existing public programmes, such as Medicaid, the federal insurance scheme for low-income Americans, and SCHIP, the State Children's Health Insurance Program, which is jointly funded by the federal government and the states, and through the creation of a new public plan. Neither candidate mandates coverage for all Americans. Obama would require only children to have health insurance, presumably paid for through the expansion of SCHIP. Perhaps the most innovative Obama proposal is a National Health Insurance Exchange, which would provide a range of insurance choices through a pooling scheme, specifically for those people who are not eligible for existing public programmes and who do not have employer-based insurance coverage. The National Health Insurance Exchange would also benefit small businesses that cannot afford to provide their employees with insurance—the group that has often proved most problematic in debates about mandated coverage. Both candidates therefore aim, commendably, to expand coverage. But just being able to afford insurance does not solve one of the biggest problems that exists in most private plans, that is, the power of insurers to deny coverage, or to charge extraordinary premiums, on the basis of applicants' pre-existing conditions. McCain says he will work with the states to create a plan that would, with the support of the federal government, guarantee coverage to people with pre-existing conditions and limit the cost of their insurance premiums, with financial aid for those who do not meet income minimums. Obama's plan would require insurers in his newly created pool to offer guaranteed coverage, and to charge a fair premium that is not dependent on the applicant's health status. We endorse both candidates' intention to remove the inequity and capriciousness of denial of coverage, though a plan that depends, as does McCain's, on the cooperation and financial support of all of the states, is certainly less likely to succeed than a federal programme. Any programme put forth by either candidate must be funded from the outset. Unfunded mandates pose obstacles in even the most trivial legislation; an issue as important as health coverage cannot be relegated to a state-by-state scramble to find the money to pay for it, or, as is most often the case, robbing one of Peter's state plans to pay for Paul's federal mandate. The issues relevant to health are not, of course, limited to insurance, as important as insurance ranks for Americans. Both candidates pledge to invest in cost-containment and quality-improvement measures. McCain wants legislation that will curb frivolous malpractice claims and protect against excessive damage payments. He wants to promote guidelines-based practice, invest in prevention and chronic-disease management programmes, and use telemedicine in remote areas. Many of Obama's proposals are similar, though he also wants to invest US$50 billion in health information technology, and plans to address the health disparities that exist across the country. That the candidates have many similar goals in the non-insurance arena comes as no surprise, since being against these improvements would be akin to opposing motherhood and apple pie. What is needed now, in the long hot days before the conventions at which the respective party platforms will be adopted, is more nuanced debate on these issues, further specifics, and increased boldness. Let the real campaign begin.