American health care is an ongoing train wreck, but donÕt expect sensible media attention to presidential plans for its reform.  Differences between employer mandated private and public plans versus tax exclusion of employer health insurance by refundable tax credits will not excite the electorate. Sound bites that little or notion to do with candidatesÕ position will continue to replace informed debate.

        Which is very unfortunate.  There are major differences between the McCain and Obama health care plans with implications for almost American. Yet the political will for change, in the teeth of opposition from a gigantic medical industrial complex, is simple not there. A nation, which spends twice as much money per person as anywhere else in the world Ð only to produce the health statistics of Cuba and Lithuania, requires reform.  But sadly Ð the plans of neither presidential candidate will survive lobbyist opposition.

The McCain Plan

        The McCain plan addresses a major inequality in present day health insurance Ð tax deductions for employer paid insurance.  If you are a hedge fund manager you can create health care insurance to cover all your health care costs, which will the government will take off your taxes.

        McCainÕs plan would replace employer insurance with a tax credit of $2500 for individuals, $5000 for families.  The uninsured would get tax credits to buy health insurance, and market competition would lead to better, more substantial coverage.  Medicare would shift from fee for service to ÒbundledÓ services paid a fixed fee.

        Sound familiar?  Remember when HMOs were going to single-handedly rescue American health care?  Market solutions have recently worked to perfection in other arenas, like our mortgage melt downs, the failure of Bear Stearns and IndyMac, and the drying up of credit for worthy businesses.

        What will your $2500 buy?  If youÕre young and healthy, some coverage with a large deductible.  If youÕre unhealthy, not much.  Medical insurance will still cherry pick off the unhealthy and ÒinsureÓ those without medical problems.

        In the 1880Õs, Germany figured out that a healthy economy, and most significantly a healthy army, required a healthy population.  You insure everybody so that the healthy help cover the unlucky and unhealthy.  You boost national production, create equity, and improve life for all.

        The McCain plan would create coverage for the uninsured only in theory.  If you become chronically sick, youÕll really be stuck.

The Obama Plan

        Barack ObamaÕs health care plan appears to provide something for everyone.  Employers will still have to pay something, but can either offer private insurance or pay a federal tax.  There will be a new government health plan something like Medicare plus a new Òinsurance exchangeÓ for those who canÕt buy group health insurance.  Cherry picking of sick patients with preexisting conditions would be outlawed.

        As Hilary Clinton pointed out again and again, ObamaÕs plan does not cover everyone.  There is no Òmandate.Ó  Presumably the government health plan would cover many of the uninsured.  More money would go into information technology and prevention protocols, but thereÕs no clear way how all this might get paid for.

The Problem of Money

        At present, American health care costs 15% of GDP while failing to cover one sixth of the population.  Most developed countries spend less than half that percentage of GDP, cover all of their populations, and show far better national health outcomes.  A recent British study had the bottom fifth of British wage earners looking more healthy than the top fifth of well insured Americans.

        As shown by the sudden national adoption of Gardasil, the cervical cancer vaccine of unknown long-term efficacy, American health care payment is driven not by health issues but by lobbyists.  American physician incomes derive from how much they use procedures and high technology benefiting large Wall Street firms that effectively lobby Washington, while general physicians, the bedrock of care everywhere else in the world, are paid the least. Preventive measures possess no clout when insurance companies see their paying clients shift year by year. Thirty percent of American costs go to administer thousands of separate insurance schemes whose rules seem to change by the day, while most developed countries spend 5-8%.

        Much like the high price of oil, the extreme costs of American health care act as a general tax on the economy.  We canÕt afford the wasteful health care we have now, and with an aging population, wonÕt in the future. WhereÕs the money going to come from?

        The answer is to ask what health care is for.  Should we continue to provide the vast majority of Big PharmaÕs national profits, and allow thirty percent of costs to go to insurance companies to administratively deny health care?  Or should the market allocate our health care dollars to travel agents and Singaporese cardiac surgery departments, whose IT is head and shoulders above that found in American hospitals?

        Health is about far more than health care.  ItÕs about how we live, how we educate our population, how we eat and move.  It is intimately connected with three diminishing resources Ð food, energy, and water (FEW) that are also deeply tied to our survival as a nation.

        There are bright spots.  The longest-lived population in the world is in the US, Asian American women in metro NY.  The group in Bergen County averages an expected lifespan of 91 years, the smaller group in Suffolk County 95.6 years.

        We must ask what weÕre getting for our health care cash. The real cost effectiveness lies in public health measures, in lifestyle and environment, not in how many liver transplants we do.  Neither McCain nor Obama address the issue of health versus health care.

        Yet a healthy economy requires a healthy population and a healthy environment.  With political gridlock on health care, we may do best to pay attention to energy policy.  Programs that support mass transport and get people out of their cars and walking may do far more for the nationÕs health than the health care tinkering weÕll see in coming years.  Both the McCain and Obama programs have worthy elements, and either will likely reach Congress - D.O.A.

Dr. Matthew Edlund practices sleep medicine and psychiatry in Sarasota.  His new book, Designed To Last, is available online. He can be reached at 365-4308 and via his Web site at doctoredlund.com.