Democrat Barack Obama's proposal is as at least as sweeping as his opponent's, but in a different way. It is certainly much more elaborate, detailed in a 15-page position paper (pdf). Obama pledges to "tackle the root causes of health disparities" in ways big and small.

Restructuring insurance: Obama would create a national health plan available to all Americans, including the self-employed and small businesses. The plan would feature comprehensive benefits, similar to those offered to federal employees (including members of Congress), and would guarantee eligibility. The insurance would be portable and affordable. Participating insurance companies in the new public program would be required to demonstrate that they meet standards for quality, health information technology, and administration.

Additionally, Obama would develop a National Health Insurance Exchange, a venue for individuals to purchase insurance, including the new public plan. The exchange would offer transparency, as well as rules and standards for participating private insurers. (Exchange plans, for example, could not deny coverage or base premiums on health status, and would have to be at least as generous as the public plan.) Meanwhile, all insurers, even those not part of the exchange, would have to dedicate a "reasonable share" of premium revenue to patient care rather than administrative costs or profit, and disclose that share. The exchange, in conjunction with the new public plan and other federal insurance programs, would also exert pressure on the medical industry by "aligning incentives for excellence" -- that is, it will reward providers for "achieving performance thresholds on outcome measures," rather than paying them for the amount of services performed.

Small firms would get a refundable Small Business Health Tax Credit of up to 50 percent against premiums they pay on behalf of their employees. Larger companies that "do not offer or make a meaningful contribution to the cost of quality health coverage" would have to pay a percentage of their payroll toward the costs of the national plan. Obama would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold, if the savings lower the cost of workers' premiums.

Obama would mandate health care coverage for all children, and expand eligibility for the Medicaid and SCHIP programs. Those who cannot afford coverage for themselves or their children but do not qualify for these government programs would get subsidies to buy insurance through the exchange.

Finally, individual states could continue to experiment with reform on their own, provided they meet the federal plan's minimum standards.

Lowering costs and improving care: Obama proposes a number of initiatives to improve medicine while lowering costs:

  • Reducing Medicare costs by allowing the government to negotiate drug prices in bulk, increasing generics, and slashing excessive subsidies under the Medicare Advantage program
  • Permitting the import of safe prescription drugs and faster introduction of new generics
  • Promoting prevention and wellness with assistance to schools, rewards for employers, and additional funding for public health training; supporting disease management programs to treat chronic conditions
  • Investing $50 billion over five years to deploy health information technology systems (including electronic medical records) and requiring a gradual implementation, while protecting patient privacy
  • Making medicine more transparent by publicizing information on treatment options and physician and provider records, particularly about medical outcomes, quality of care (including preventable errors), costs and prices
  • Establishing an independent institute to direct investigation into comparative effectiveness, and promoting "new models for addressing errors that improve patient safety, strengthen the doctor-patient relationship and reduce the need for malpractice suits"
  • Strengthening antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance.

Other health initiatives:

  • Increase funding for biomedical research, and improve coordination both within government and with outside partners
  • Fight AIDS worldwide
  • Strengthen and improve enforcement of the Americans with Disabilities Act, and make Medicaid and Medicare more accessible to the disabled
  • Support parity for mental health coverage
  • Reduce mercury contamination in waterways, and require lead-safe child care facilities within five years
  • Fund at least $1 billion in autism research and increase funding for the Individuals with Disabilities Education Act

The Obama Record: Obama has voted consistently to strengthen and increase access to government public health initiatives -- he voted with the APHA 100 percent in 2006 and 2007. "He's been very good on prevention and public health, on the state level as well as nationally," says the APHA's Benjamin. But, he adds, Obama isn't perfect: on the organization's 2005 scorecard, "he got an 80."