Lowering healthcare costs
One aspect of Sen. McCain’s plan attempts to control costs by increasing competition among insurance companies. He would establish a national market, rather than subject insurance companies to a plethora of state rules and regulations. This would enable companies to compete across state lines and subject them to greater free market forces.

As a result of increased, nationwide coverage, he believes insurance companies would be forced to lower premiums, improve healthcare coverage, and achieve better economies of scale to attract more policyholders. Patients would benefit by having more health insurance options to better fit their needs.

Expanding the benefits of Health Savings Accounts (HSAs) is another proposal that Sen. McCain believes will result in lower costs. By putting patients in control of their own healthcare spending, he believes they will decide which procedures and treatments are necessary and unnecessary and thus decrease costs.

Lowering drug prices by allowing more rapid introduction of generic drugs is also part of his plan to cut healthcare costs.

Chronic conditions and coordinated care
Sen. McCain promotes the concepts of disease prevention, early intervention, healthy habits, public health infrastructure, and the use of information technology to reduce healthcare costs. He would dedicate more federal research dollars to disease prevention and improved management of chronic diseases, ultimately resulting in reduced healthcare costs over the long term.

He believes that increasing the transparency of healthcare cost and physician reimbursement will promote competition and lower costs. Under his proposal for coordinated care, a single bill would cover comprehensive care of one diagnosis or treatment. For example, one reimbursement would cover all the care for a single treatment event such as hip replacement surgery. The patient would receive only one bill, covering preoperative visits, laboratory tests, surgery, hospitalization, radiographs, medications, and follow-up care.

Although the concept of providers working together to coordinate patient care is readily understood, how the single-bill system would be implemented is unclear. Whether fees for specialists would be included or how the reimbursement would be divided among various providers—such as hospital inpatient costs, radiology fees, or surgeon fees—has not yet been outlined.

The need for tort reform
Sen. McCain strongly supports medical liability reform, believing that trial lawyers have contributed to escalating healthcare costs. Many AAOS members have also been actively involved on this issue through Doctors for Medical Liability Reform. Sen. McCain envisions reforms to eliminate frivolous lawsuits against physicians and to establish clinical guidelines and patient safety protocols that protect patients while guaranteeing them the highest quality of care.

Power to the people
Sen. McCain wants to give individuals greater power over their own healthcare decisions. He proposes giving individuals and families the opportunity to purchase their own health insurance by transferring the tax credit employers currently receive when they purchase health insurance for their employees to the employees themselves.

Under this plan, an individual would receive a $2,500 tax credit ($5,000 for families) to purchase insurance. The individual would select the company and plan, and the government would pay the tax credit directly to the insurance company. Any net credit that remained after paying premiums could be added to the individual’s HSA.

Individuals who purchased coverage under this proposal could take their healthcare plan with them if they changed jobs. But those with employer-provided coverage could elect to stay with their employer-based healthcare plan. Sen. McCain believes such a plan would increase both choice and control for patients, increase competition among insurance carriers, and help contain healthcare costs.

Sen. McCain proposes making coverage more affordable for all citizens but does not call for a mandated or federally based insurance plan to guarantee coverage for all. Instead, he proposes a Guaranteed Access Plan (GAP) for individuals who have a preexisting medical condition and have been denied health insurance coverage. These individuals would have the opportunity to join state-supported plans that would have limits on premiums and financial assistance for those with incomes below a certain level.

Will they work?
Several healthcare economists and analysts have raised concerns about some of Sen. McCain’s proposals. Removing the tax credit for employers and allowing employees to purchase their own insurance plans, they say, might mean that employers will discontinue offering healthcare coverage as part of an employee benefit package. Although this is possible, it is not likely to happen very quickly.

Analysts note that those most likely to opt for self-purchased healthcare plans are the young and healthy, whose premiums would be lower than their tax credit. The group least likely to shop for personal coverage would be older (and sicker) employees. The increased disease burden could increase costs for employers.

One criticism of the tax credit plan is that the credits are not significant enough to truly offset the costs of healthcare. A typical plan for a family of four costs an estimated $12, 000 a year, more than double the $5,000 family tax credit. The final costs of Sen. McCain’s proposals are unknown; some analysts predict the changes would cost several times the current estimates.

Impact on orthopaedics
How Sen. McCain’s proposals will affect the practicing orthopaedic surgeon is unclear. The proposal for a single-bill system for a healthcare event or chronic disease management is not fully developed. Such a system could negatively affect reimbursement for orthopaedic care such as total joint arthroplasty.

If Sen. McCain could implement medical liability reform on a federal level, malpractice rates across the country could decrease. Expanding HSAs, achieving medical liability reform, establishing best-practice national clinical guidelines, and empowering patients to control more of their healthcare dollars and decisions could reduce liability and enable orthopaedic surgeons to practice best-practice medicine instead of defensive medicine. Moreover, the GAP program, which would extend coverage to individuals who have been denied insurance or priced out of the market due to preexisting conditions and high individual risk, could encourage previously uninsured patients with orthopaedic needs to acquire insurance and seek out appropriate care.

For more on Sen. McCain’s healthcare proposals, as well as information on his position on other issues, visit the campaign Web site at www.johnmccain.com

The Washington Health Policy Fellows include John H. Flint, MD; Ryan M. Nunley, MD; Aaron Covey, MD; James Genuario, MD, MS; A. Alex Jahangir, MD; Samir Mehta, MD; Sharat K. Kusuma, MD; Anil Ranawat, MD; and Alok D. Sharan, MD.