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McCaincare: Provocative but VagueThe health-care primary, Part 5.

By Timothy Noah
Updated Tuesday, Oct. 16, 2007, at 6:30 PM ET
John McCain. Click image to expand.

A principle I've tried to uphold in writing this series is that a candidate's health-care plan is not what some campaign aide says it is when speaking to a reporter on background, but rather what the candidate's own campaign literature says in black and white. As Curtis Armstrong tells Tom Cruise in Risky Business, "If you can't say it, you can't do it."

This principle was put to the test by John McCain's health plan, which is very poorly explained on the McCain campaign Web page labeled "Straight Talk on Health System Reform." This "straight talk" consists almost entirely of airy platitudes. A multimedia page that links to a petition signing on to McCain's health plan is similarly unhelpful. (How can you sign the petition—really a fund-raising gimmick, of course—if you don't know what the damn health plan is?) Slightly more helpful is this transcript of a speech McCain gave Oct. 11 to Rotarians in Des Moines, Iowa. Even here, though, I needed help interpreting this potentially significant passage:

Like most of our system, Medicare reimbursement now rewards institutions and clinicians who provide more and more complex services. We need to change the way providers are paid to focus their attention more on chronic disease and managing their treatment. This is the most important care and expense for an aging population. And in a system that rewards quality, Medicare should not pay for preventable medical errors.

We need to change the way providers are paid.

Until now, we've heard the candidates discuss, ad nauseum, ways to change who pays doctors and hospitals for medical care—the choices being the patient, the insurer, the government, or some more-feasible blend of these three—but we haven't heard them talk about changing how those doctors and hospitals should be paid. Possible reform in this area would be far more radical than anything proposed by the Democratic presidential candidates, even if confined only to Medicare. Does McCain really mean to change how doctors and hospitals are paid? If so, how would he change it?

McCain's publicly available material doesn't say. So I broke my rule, phoned the campaign, and requested an interview with anyone who might be able to explain. In essence, I learned, McCain is challenging fee-for-service medicine, though not to the point of mandating that doctors be put on salary. Under the present fee-for-service payment scheme, doctors have an economic incentive to maximize their income by performing as many medical procedures as possible. That drives up costs, overtaxes hospitals, and threatens patients' lives. McCain deserves congratulations for taking on the fee-for-service problem, even if his proposed solution is short on specifics.

The rest of McCain's health-care plan is an uninteresting mishmash of proposals that are mostly useless and occasionally harmful.

Candidate: John McCain

Elegance: None. As noted above, clarity is a problem, too.

Market gimmicks: The main one is health savings accounts, which "put the family in charge of what they pay for, and should be expanded and encouraged." Actually, health savings accounts are a roulette game that favors young, healthy people who don't expect to get sick. If they get sick anyway, they're screwed. If they don't get sick, they're screwing those who do by reducing funds available for the larger risk pool.

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Timothy Noah is a senior writer at Slate.
Photograph of Nicholas Kamm/Agence France-Presse/Getty Images. Photograph of John McCain on Slate's home page by Mark Wilson/Getty Images.
E-mail Timothy Noah at .
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