You know things are bad when an insurance company tries to fix the health care system.

WellPoint Inc. is funding a competition in collaboration with X Prize Foundation to devise solutions that improve health care cost and quality. Although the actual award amount and competition guidelines won’t be ready until early 2009, the rumored jackpot is about $10 million.

According to the X Prize site , the two partners will solicit advice from various stakeholders, hold the competition, and test the finalists’ plans in WellPoint’s markets. (WellPoint is a large licensee of Blue Cross Blue Shield Association.) The prize will be awarded only if the solution proves effective.

I can only assume that X Prize and WellPoint have considered the health care landscape will likely change, and perhaps drastically, in the next few years. How much change will depend on who we elect as President in November.

The candidates have touched on the topic in the recent debates, but the confines of the televised format have impeded a leisurely examination of the two proposals. Luckily, we won’t have to rely on Google or snarky campaign ads for non-peer reviewed information – the Oct. 16 issue of the New England Journal of Medicine has added a little meat to the woefully skimpy bones of my “candidate health care plan” knowledge. Break out the A1 steak sauce and grab your fork, everybody.

(N.B. I presented the points in the same order as listed in NEJM; I’m not advocating one position or the other.)

Dr. Blumenthal, who writes about McCain, sets the scene nicely:

“The most important questions raised by the health care proposals of the presidential candidates concern their values and judgment. These will guide a new president through the tortuous, unpredictable process of leading health care change. The specifics of candidates' proposals matter. But more important is what health plans communicate about a prospective president's fundamental beliefs and character.”

“Primum Non Nocere – The McCain Plan for Health Insecurity” – Dr. David Blumenthal, Massachusetts General Hospital, unpaid advisor to Obama campaign

For those who are not lexical Latin wizards, Blumenthal ’s title translates into “First, do no harm.” It begs the question – to whom should we do no harm? And how are we harming them anyway? My take on Blumenthal’s message: McCain’s social conservatism would threaten access to insurance for millions of Americans.

“By this standard, John McCain emerges not as a maverick or centrist but as a radical social conservative firmly in the grip of the ideology that animates the domestic policies of President George W. Bush. The central purpose of President Bush's health policy, and John McCain's, is to reduce the role of insurance and make Americans pay a larger part of their health care bills out of pocket. Their embrace of market forces, fierce antagonism toward government, and determination to force individuals to have more “skin in the game” are overriding — all other goals are subsidiary. Indeed, the Republican commitment to market-oriented reforms is so strong that, to attain their vision, Bush and McCain seem willing to take huge risks with the efficiency, equity, and stability of our health care system. Specifically, the McCain plan would profoundly threaten the current system of employer-sponsored insurance on which more than three fifths of Americans depend, increase reliance on unregulated individual insurance markets (which are notoriously inefficient), and leave the number of uninsured Americans virtually unchanged. A side effect of the McCain plan would be to threaten access to adequate insurance for millions of America's sickest citizens.”

Blumenthal argues that McCain’s plan would end the exemption from federal income tax for employer-sponsored insurance and undermine care for the chronically ill.

“The choice facing health care professionals, like all Americans, is basic: Who deserves to be trusted with the stewardship of America's health care system? The McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care. Senator McCain's plan does not demonstrate the kind of judgment needed in a potential commander in chief of our health care system.”

So, would spending more and expanding access help? Dr. Antos says no.

“Symptomatic Relief, but No Cure – The Obama Health Care Reform” – Dr. Joseph Antos, American Enterprise Insitute 

My take on Antos ’ message: Antos suggests Obama’s plan for reform is too costly for the American consumer.

“A central premise of Senator Barack Obama's campaign for the presidency is that America is ready – this time – for sweeping health care reform. He has laid out a vision for reform that promises health insurance for (nearly) everyone, with coverage as good as that enjoyed by members of Congress. According to the campaign, the Obama plan would shift most of the 46 million uninsured Americans into health plans, strengthen employer-sponsored insurance, increase the efficiency of the health care delivery system, and save the average family $2,500 a year on their insurance premiums. These hopes are too audacious to be believed. The Obama plan offers a host of policy proposals that, in the main, address the symptoms but not the underlying disease that afflicts the health care system. We surely could use some symptomatic relief. However, failing to address the perverse incentives that drive health care spending inexorably upward, making insurance unaffordable for millions and shaping (or misshaping) the practice of medicine, will leave us worse off than we are today.”

Antos argues that Obama’s reforms “come with a big price tag” – higher out-of-pocket costs for consumers, less competition among insurers and high risk of government failure.

“Early in his campaign, Obama recognized that the success of health care reform rests on the plan's ability to slow spending growth and make health care affordable for everyone. His plan would reorganize the health-insurance market – but not change the basic financial incentives in the system that drive up spending. Although the plan would significantly increase the number of Americans with health insurance, it remains to be seen whether that would come at a price Americans would be willing to pay.”

Finding a common ground – dreaming the impossible dream?

On one hand, we don’t spend enough and people who really need insurance won’t get it. On the other hand, we spend too much and people (and the government) risk financial ruin. Is there a common ground? Will the next President and Congress be able to muddle through to reach an acceptable compromise, or will industry (with the help of stakeholders) beat them to it?