The third and final presidential debate between Republican John McCain and Democrat Barack Obama, held Wednesday night at Hofstra University in Hempstead, N.Y., was expected to be a heated afair and vital to McCain, who trails in the national polls.
While the economy dominated the discussion, healthcare made its way for the third time into the debate, with McCain calling Obama's plan "big government at its best," and Obama arguing that McCain's plan could unravel the current employer-based system.
Topics selected by moderator Bob Schieffer of CBS included the economy, negative ad campaigns and the qualifications of vice presidential running mates. On healthcare, Schieffer asked, "Given the current economic situation, would either of you now favor controlling healthcare costs over expanding healthcare coverage?"
Obama, chosen by Schieffer to answer first, said, "We've got to do both, and that's exactly what my plan does. As I travel around the country, this is the issue that will break your heart over and over again."
The Illinois senator said his healthcare plan would allow Americans to keep coverage through their employer, exactly as it is, at lower costs, saving the average family $2,500 a year in premiums. Those without coverage could buy into a plan similar to that offered to federal employees, allowing high-quality care and a choice of doctors at lower rates "because so many people are part of this insured group."
Obama said under his plan insurance companies would not be allowed to discriminate on the basis of pre-existing conditions.
To manage costs, he said he would have the federal government negotiate cheaper drug prices and invest federal funding in health information technology to eliminate bureaucracy and "make the system more efficient." He also called for stronger emphasis on preventive medicine to manage costly preventable chronic illnesses, such as diabetes and heart disease.
"This will cost some money on the front end, but over the long term this is the only way that not only are we going to make families healthy, but it's also how we're going to save the federal budget, because we can't afford these escalating costs," Obama said.
In response, McCain called the U.S. healthcare system "a terribly painful situation for Americans."
The Arizona senator called for electronic health records to reduce healthcare costs and for more community health centers and walk-in clinics.
McCain said the rise of obesity among young Americans is an "alarming statistic" that should be addressed with physical fitness and nutrition programs in schools. He also said he would encourage employers to reward employees who join health clubs.
McCain's healthcare reform plan would give every American family a $5,000 refundable tax credit to be used to purchase healthcare anywhere in the country.
McCain accused Obama of wanting to set up "healthcare bureaucracies" to "take over the healthcare of America" through a so-called single-payer system. He also said Obama's plan threatened to fine small businesses who do not provide healthcare.
Obama said he would exempt small businesses from requiring healthcare, but would provide a 50-percent tax credit as an incentive to providing coverage. He said he would call for larger businesses to provide healthcare to their employees if they are not already doing so.
"I exempt small businesses from having to pay into a kitty. But large businesses that can afford it, we've got a choice," Obama said. "Either they provide health insurance to their employees or somebody has to. Right now, what happens is those employees get dumped into either the Medicaid system, which taxpayers pick up, or they're going to the emergency room for uncompensated care, which everybody picks up in their premiums."
"The average family is paying an additional $900 a year in higher premiums because of the uninsured," he said.
Obama, in turn, said McCain's plan would drain employer-based health insurance of the less expensive, healthy, younger consumers who can purchase health insurance elsewhere. This would leave older and less healthy Americans in shrinking employer-based pools that would become too expensive for businesses to retain, he said.
Obama said McCain's plan could leave some 20 million people without employer-based coverage and with pre-existing conditions that may preclude them from purchasing healthcare elsewhere.
He accused McCain's plan of taxing healthcare benefits "for the first time," as McCain's plan calls for taxes on employer-based health benefits. He also said healthcare costs average $12,000 for the average American family, not the proposed $5,000 under McCain's proposal.
McCain's proposal to lift state restrictions on health insurance companies would allow them to cherry pick and exclude people from coverage, Obama said. He called this "a mistake" and said he and McCain have fundamental differences on how they would approach healthcare.
McCain attacked Obama for wanting to "spread the wealth," hard-earned by richer Americans.
Speaking to "Joe the plumber," someone that he said he had encountered on the campaign trail, he said, "You're rich. Congratulations. And you will then fall into the category where you'll have to pay a fine if you don't provide health insurance that Senator Obama mandates – not the kind that you think is best for your family, your children, your employees, but the kind that he mandates for you."
McCain said 95 percent of the nation will receive more money under his plan because they will receive not only their present benefits, which will be taxed, but the added $5,000 tax credit.
"And the good thing about this is they'll be able to go across America" to purchase healthcare, he said. "This will give them a chance to choose their own futures, not have Senator Obama and government decide that for them."
McCain said it all comes down to fundamental philosophical differences.
"If you notice that in all of this proposal, Senator Obama wants government to do the job. We've got too much government and too much spending – the size of government has grown by 40 percent in the last eight years."