WASHINGTON — If John McCain becomes president, Americans would be steered toward buying individual health insurance policies, and job-related coverage eventually could decline. If Barack Obama or Hillary Rodham Clinton wins, more people would get their insurance from the government -- with many workers offered the equivalent of Medicare and employers facing new coverage mandates.
In the past, voters sometimes have complained that there was little difference between Republicans and Democrats. That's far from true in the 2008 campaign, at least where healthcare is concerned. On this issue, which many voters rank near the top of their concerns, the two parties offer clear choices.
The Democratic and Republican candidates espouse similar goals: making medical insurance more available and more affordable for more Americans. But their strategies for achieving those goals are fundamentally different. So are the ways in which, over time, the nation's healthcare system would change.
McCain, for example, says he would give individuals more freedom of choice; critics say he could destabilize the employer-based system that the middle class has relied on for more than half a century.
Clinton and Obama, meanwhile, say their fairly similar strategies would give better and more affordable coverage to more -- eventually all -- people; critics say they would march the country toward socialized medicine.
For the approximately 60% of Americans covered by employer-provided health insurance, none of the plans would bring dramatic changes overnight. But over a period of years, employer-based coverage could decline.
McCain's way is to de-emphasize job-based insurance and encourage people to choose their own coverage in a yet-to-be-created national marketplace; he would offer tax credits to help them pay for such coverage.
The Democrats' approach is to shore up the kinds of large pools that traditional insurance programs rely on -- using the premiums of the many who don't file claims in any given period to pay the claims of the relatively few who do.
They would also put the insurance industry on a tighter regulatory leash.
"The specifics can be sort of mind-bending, but on the very broad choices, McCain emphasizes a vision where individuals get more choices in the marketplace and are less reliant on employers and government," said Robert Blendon of the Harvard School of Public Health, an expert on public attitudes about healthcare reform.
