A great debate on the great divide...

Friday, June 06, 2008

There's few general-interest political reporters who get health policy and health issues like Ron Brownstein of the National Journal (and formerly from the Los Angeles Times). Now with the primaries over, he clearly and fairly lays out the choice between the plans of the presidential candidates, and it is stark.

His two recent articles in May, The Health Care Divide, and Going Solo, deserve to be read in full, but here are excerpts (the emphasis is mine):

The Health Care Divide
by Ronald Brownstein, National Journal, Sat. May 17, 2008

Countless details separate John McCain's health care proposal from those of the Democratic presidential contenders. But the most significant difference is fundamental and philosophical. The two sides are offering divergent visions about the basic role of health insurance in the nation's social safety net. The fork in the road could not be starker.

The plans unveiled by Barack Obama and Hillary Rodham Clinton encourage the sharing of risk between the healthy and the sick, even at the cost of requiring the former to subsidize the latter. McCain's proposal would maximize individual choice in obtaining coverage, even at the cost of reducing risk-sharing. This contrast, which reflects the broader divide between the Democratic emphasis on community and the Republican focus on personal freedom, is the wellspring from which all of the major differences in the candidates' plans flow.

Confused press coverage and McCain's shift to other issues have obscured the magnitude of his proposal. But he may be pushing for greater changes than the Democrats in both the way Americans pay for health insurance and how they buy it--changes that have potentially profound implications for the pooling of risk...

America subsidizes employer-provided coverage this way partly because it is administratively efficient, but mostly because it promotes the pooling of risk. By putting young, healthy workers into the same risk pool as colleagues who are older or sicker, employer-based coverage supports cost-sharing...

McCain's plan could threaten these arrangements, although how much is uncertain. He would eliminate the tax "exclusion," so that health premiums paid by employers would count as taxable income for workers. But he would replace the current exclusion with a refundable tax credit of $2,500 for individuals and $5,000 for families...

But almost all analysts think that without the economic incentive that the exclusion provides, some employers would drop coverage. The great unknown is how many. Even employers who want to maintain coverage might find it increasingly difficult to do so...

These dynamics could prompt a modest shift from group coverage to individually based insurance--or a massive exodus...

There's been a lot of heat about the debate at the federal and state levels around the idea of an "individual mandate." What Brownstein points to is a far more central debate: group vs. individual coverage. Since people want coverage, the issue was not so much the individual mandate, but the individual market.

When Health Access and other groups evaluated a health reform proposal here in California, one of the key barometers we looked at was whether it increased or decreased the number of Californians subject to the individual insurance market, the least efficient, most expensive way to get coverage, where the consumer is alone, at the mercy of the big insurers.

Schwarzenegger's original health reform plan expanded group coverage, but also expanded the individual market, but with some important improvements (guaranteed issue, medical loss rations, etc.) While consumer advocates supported many of those insurance reforms (like the insurance standards in this year's SB1522), we still preferred the benefits of group coverage.

The negotiated plan, AB x1 1, got support in part because the modelling showed that it shrank the individual market, while also attempting to fix it for those who are left.

McCain's plan does the worst of both worlds--it shifts millions into the individual market, as he deregulates the market as the same time!

Going Solo
by Ronald Brownstein, National Journal, Sat. May 24, 2008

Today, most Americans receive health insurance through large organizations (either their employer or the government). Only a small number of them (about one in 11) buy it on their own in the individual insurance market.

Almost all experts agree that the health care proposal that presumptive GOP nominee John McCain recently announced would shift that balance--perhaps substantially--toward individually purchased coverage. McCain wants to replace the tax benefit for employer-provided coverage with a personal tax credit of $2,500 for individuals and $5,000 for families. That trade would cause some companies to drop coverage, driving an unpredictable number of their workers from employer-based insurance to individually based plans...

That raises an obvious question: Could the individual market handle the load? A wide variety of experts, including some in the insurance industry, say that the answer, at least for today, is no.

For starters, the administrative costs of individual policies are at least triple those of employer-based policies. That means a worker shifting from a group policy to an individual one receives significantly less coverage for the same price, notes Kenneth Thorpe, an Emory University health policy professor. And although group policies share risk between the young and old, the healthy and sick, the cost of individually based policies varies enormously, depending on the person's health. Most important, people with prior health problems often cannot get affordable coverage--if they can get any at all. "If you are a 60-year-old woman with multiple chronic diseases, forget it," Thorpe says. "There is nowhere for you to go in the individual market."

America's Health Insurance Plans, the industry's trade association, insists that the individual market works better than Thorpe and similar critics believe. But, tellingly, even AHIP is not arguing for more reliance on individually based insurance. "We haven't advocated that," says Karen Ignagni, the group's president. AHIP has endorsed a McCain-like tax credit for the uninsured, but it opposes eliminating the tax break for employer-based coverage.

McCain would respond to the problems in the individual market by massively deregulating the insurance industry, a step that he argues would promote productive competition. Each state currently sets minimum standards for the health insurance plans sold within its borders. McCain would override that state regulation by allowing health insurers to sell in every state any policy approved in any state. That would mean states could no longer require insurers to pay for specific medical procedures (such as mammograms) or establish coverage requirements (such as maximum deductibles) if any other state set a looser standard. The state that regulates least would set the rules.

...many experts argue that McCain would be courting disaster by deregulating the insurance industry just as his plan drove more people into the already turbulent individual market. That could produce massive premium increases and diminished (or no) coverage for people in poor health. Again, it is revealing that even AHIP has not endorsed nationwide insurance sales.

While McCain would deregulate the industry, Democratic contenders Barack Obama and Hillary Rodham Clinton would restructure it by imposing new national standards. Each Democrat would establish government-organized purchasing exchanges for individuals and small businesses, and would require insurers participating in them to sell to all applicants at comparable prices, regardless of their health. The Democratic plans would face their own political challenges, but none may be as daunting as McCain's task of convincing Americans that the health care system will work better for average families if there is less regulation of the insurance industry, not more.

With the primaries over, I hope the medica coverage really focused on this clear distinction between the two candidates. It's never been as clear, or as important.

Labels: Insurers, InTheNews, PresidentialCandidates, YearOfReform

posted by Anthony Wright | Permalink | 10:49 AM


 

Healthy blogging...

Sunday, June 01, 2008

Those interested in health policy should be subscribed to the news summary that the Kaiser Family Foundation puts out on a daily basis. Now, those summaries will often include a health policy blog roundup, which will be another way to keep up-to-date. Here's several gold nuggets they found from panning the blogosphere about McCain's health plan:

Joe Paduda of Managed Care Matters examines presumptive Republican presidential nominee Sen. John McCain's (Ariz.) health care plan and whether it could increase the number of uninsured residents by destabilizing the employer-based health care system. Robert Laszewski of Health Care Policy and Marketplace Review builds off of Paduda's post to argue that McCain's market-based plan reforms might work well for some voters, as long as advisers present certain changes carefully. Bob Vineyard of Insure Blog reacts to a Slate article and discusses McCain's proposal to allow individuals to purchase insurance across state lines. Peter Harbage from the Wonk Room Blog discusses a new Center for American Progress Action Fund paper about McCain's health care plan and administrative costs.

Really good stuff there.

Don't forget the biweekly Health Wonk Review, which this week is hosted by Hank Stern at InsureBlog. We are listed in there with over a dozen interesting posts from around the web.

Finally, for those who prefer to read offline, our state-based colleagues at the Connecticut Health Policy Project have a blog of interest, CT Health Notes Blog, and have a recommended booklist for your summer reading.

Labels: OtherBlogs, OtherStates, PresidentialCandidates

posted by Anthony Wright | Permalink | 1:10 AM


 

The first 100 days...

Friday, May 30, 2008

It's a busy day blogging on the budget, but I would be remiss if I didn't point out a statement by Sen. Barack Obama made last night in Denver, as reported by Marc Ambinder of the The Atlantic.

So after he meets with the Joint Chief of Staff to determine a course of action in Iraq, Obama wants to "[G]et our health care plan moving. We need a bill...by March or April to get going before the political season sets in."

Ezra Klein of The American Prospect is elated, citing that the previous Clinton effort suffered because it was pushed back and not considered in the first 100 days. But we health advocates still have a lot of work to do, to make sure that health reform, and the right reform, is the top priority in Washington, DC, as well as Sacramento.

Labels: Federal, PresidentialCandidates

posted by Anthony Wright | Permalink | 5:03 PM


 

More on high risk highjinks...

Saturday, May 17, 2008

Our post on the state of California's high-risk pool, MRMIP, has gotten web attention by the new Health Wonk Review, hosted at the Healthcare Economist this week, and by multimedia globetrotting journalist Sarah Arnquist at The Health Care Blog, on a post about people so desperate for coverage--and yet denied in in the individual market--that they'll marry in order to get good group coverage.

Again, the focus here is the key. Consumer advocates are actively working to improve the sorry state of the individual market--Health Access has a bill, SB1522(Steinberg), to better standardize the market, so that people have a better sense of what they are getting. AB1945 (De La Torre) has provisions to place oversight over any rescissions, and in fact to standardize the underwriting procedures of insurers, such as the dreaded questionnaire. And then there's AB2 (Dymally) to improve the high-risk pool for those who are denied because of pre-existing conditions.

While all these reforms are needed in the individual market, a preferred solution is to avoid these problems altogether by having people come together in groups (whether through employers, public programs, or large purchasing pools) to get coverage. In contrast to the Obama, Clinton, Edwards, Hacker, Kuehl, and Nunez/Schwarzenegger plans, the McCain plan actively works to shift people from group coverage into the individual market, and that's the fatal flaw. McCain may offer some support of state "high-risk" pools as a way to "solve" the problem--a worthy effort by itself--but the very nature of his proposal makes the problem that needs to be solve--people facing denials for "pre-existing conditions"--much worse, and his solution doesn't begin to undo the damage.

Labels: Insurers, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 8:46 AM


 

More on McCain...

Thursday, May 01, 2008

There's a new May Day edition of the Health Wonk Review up at the Medical Humanities blog.

While they spotlight our post on McCain's health "plan," I want to recommend Jonathan Cohn at the New Republic for his analysis, as well as a discussion on Time.com's Curious Capitalist and Swampland, which has lots of links as well.

Basically, the nicest things I've heard about the McCain plan is it won't do any harm because it really isn't a fleshed out plan, and it doesn't have a chance in Congress. However, the majority think it's a radical shift--and not in a good way.

One debate started in Time.com's Swampland here, which quotes health policy expert Robert Blendon.

McCain's--which has some of the features of a plan proposed by George Bush in 2007, which didn't go anywhere in Congress*--actually envisions an entirely new system in which individuals would shop for their own health care coverage, presumably getting a better deal thanks to vastly more competition in the marketplace. "He proposes a vision for the future that doesn't exist -- yet," Blendon says. "His argument is I'm going to change how this thing works. ... In some sense, he has the largest scale what you would call 'reform' of all the candidates."

On the other hand, the assumption underlying the Obama and Clinton plans is the opposite, says Blendon, that "the worst thing that can happen to people is to be by themselves trying to negotiate for insurance. ... The solution is protecting people from being out there by themselves" by pooling them together, either through the workplace or in newly created purchasing cooperatives.

A commentator agrees, and succinctly lays out the three main reasons why not to shift people to the individual market:

1. Individuals have less bargaining power and sophistication than employers.
2. Negative selection.
3. Greater frictional costs from advertising to individuals, etc.

Pretty good, although they are linked. Because the individual has so little power against a big insurer, individuals usually get charged more expensive rates, and insurers profit more from the individual market. Since they lack purchasing power, they also can excluded on a case-by-case basis (as opposed to group coverage, where part of the deal is to take the entire group). And finally, the administrative and marketing costs are far more example when the company is managing and selling the plans one-at-a-time, as opposed to a group.

Individual buying coverage are simply not getting the same bang for their buck as those in the group market. Why Bush, McCain, and others would want to take coverage in that direction is beyond me.

Labels: OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 11:26 PM


 

High-risk health reform...

Tuesday, April 29, 2008

John McCain is getting beaten by a woman, and it's not Hillary Clinton. It's Elizabeth Edwards.

In unveiling his health care plan, McCain seems super-focused on the fact that many more people could be denied coverage because of "pre-existing conditions," as he seeks to shift people from employer-based coverage to the individual insurance market, with some assistance from a tax credit.

Elizabeth Edwards pointedly has challenged McCain, saying that an American with her or his health history would be denied under McCain's plan in the individual insurance market. (To be fair, the Los Angeles Times made this point earlier.) She's absolutely right.

And because of this, McCain has a liability. He even has a "myth and facts" section of his website designed to counter exactly one, and only one, myth:

"MYTH: Some Claim That Under John McCain's Plan, Those With Pre-Existing Conditions Would Be Denied Insurance.

FACT: John McCain Supported The Health Insurance Portability And Accountability Act In 1996 That Took The Important Step Of Providing Some Protection Against Exclusion Of Pre-Existing Conditions.

FACT: Nothing In John McCain's Plan Changes The Fact That If You Are Employed And Insured You Will Build Protection Against The Cost Of Any Pre-Existing Condition.

FACT: As President, John McCain Would Work With Governors To Find The Solutions Necessary To Ensure Those With Pre-Existing Conditions Are Able To Easily Access Care."

The multiple "facts" don't really the answer the charge. The "myth" is a factual statement. Where do those those with "pre-existing conditions" go under the McCain plan? Some will get left behind. In the new twist to the slim pickings already on his website, McCain would now have states figure out how to solve the issue of the "uninsurables." .The New York Times coverage by Michael Cooper and Kevin Sack focus on this aspect. Bob Laszewski from Health Care Policy and Marketplace Review thinks McCain has opened a major liability for himself.

I think the Democratic rivals made good responses but didn't quite capture the central critique of this plan in their responses.

* Some of what they say is a criticism of what is *not* in McCain's plan, which indicates it lacks a certain ambition, but doesn't really say why the proposal is still not an improvement from the status quo. (Frankly, it doesn't take much.)

* Clinton appropriately criticizes state high-risk pools (and her statement--"virtually all high-risk pools today have waiting lists, high premiums, and scaled-back benefits"--is a dead-on description for California's MRMIP, Managed Risk Medical Insurance Program, which now has a waiting list, is underfunded, has high premiums and a $75,000 benefit cap.)

* But in our current system, the state high-risk pools are an essential lifeline to coverage for many. The problem is not the high-risk pool itself, but the major people who are denied in the individual market, that the high-risk pool provides some comfort.

* The real issue is not the high-risk pools in the state as a solution, but that his plan seeeks to make the problem much bigger. The more he accomplishes his goal of moving people from group coverage (like that of their employer) to individual coverage, the more he creates the problem that he seeks to solve.

Here in California, Health Access California supports AB2 (Dymally) and other efforts to improve and better fund our high-risk pool, so more people, denied for pre-existing conditions, can at least get some coverage.

We were more pleased to support AB x1 1, the negotiated reform between the Governor and the Speaker, that included not only guaranteed issue--so no insurers could deny for health status--but it would expanded group coverage enough that there was a net decrease in the number of people having to get individual coverage.

This was important, because the individual market is fundamentally a place where the individual has little market power against the big insurers, as opposed to when they at least have the purchasing power of a group. McCain would place more people in the individual market.

So the criticism isn't that McCain relies on state-based high-risk pools, it's that he would increase the need for them in the first place.

Labels: Insurers, InTheNews, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 11:42 PM


 

The new McCain plan, and his opponent(s)

Ben Smith at Politico usefully put forward a link to the revised McCain health care plan that was spotlighted in a speech by the Arizona Senator today. He also quoted the responses by the two Democratic presidential campaigns:

Sen. Clinton:

John McCain is proposing a radical plan that would mean millions of Americans would lose their job-based coverage: The McCain plan eliminates the policies that hold the employer-based health insurance system together, so while people might have a ‘choice’ of getting such coverage , employers would have no incentive to provide it. This means 158 million Americans with job-based coverage today could be at risk of losing the insurance they have come to depend upon.

While Senator McCain touts the choices his plan offers, people who are older or sicker would actually have no choice under his new proposals. Older Americans or those with pre-existing conditions would be allowed to get only one type of coverage in a high risk GAP pool. That kind of arrangement does more to help insurers than individuals. In addition, high-risk pools fall far short of helping people in need. Virtually all high-risk pools today have waiting lists, high premiums, and scaled-back benefits. The millions of vulnerable Americans who lose employer-based coverage could have to wait months, maybe years, to access the GAP high-risk pools, if they are like the pools that exist today.

To top it off, Senator McCain has offered no straight talk on how he would pay for these initiatives.

Sen. Obama (via spokesman Hari Sevugan):

At a time when 47 million Americans don't have health care, and millions more are being driven to financial ruin trying to pay their medical bills, John McCain is recycling the same failed policies that didn't work when George Bush first proposed them and won't work now. Instead of taking on the big health insurance companies and requiring them to cover Americans with preexisting conditions, Senator McCain wants to make it easier for them to reject your coverage, drop it, or jack up the price you pay. But the only choice he's offering the American people is a tax break that won't guarantee coverage and doesn’t ensure that health care is affordable for the working families who need it most. Barack Obama has a universal health care plan that will cover every American and cut the cost of a typical family's premiums by up to $2500 a year.

Labels: PresidentialCandidates

posted by Anthony Wright | Permalink | 3:02 PM


 

From the World Health Care Congress...

Wednesday, April 23, 2008

Just wanted to spotlight some of the blog posts and reports from the World Health Care Congress, now at the World Health Care Blog.

Joe Paduda of Managed Care Matters has an excellent report, especially his commentary on the presentations by the presidential campaigns, as well as other panels. ChangeNow4Health also has notes from that panel. Notes are also taken by jenmccabegorman and ajfortin on Twitter.

With the Pennsylvania primary just past us, Richard Eskow at the Sentinel Effect has more opinion about the presidential plans.

Here's my basic gist: the Clinton and Obama plans are very similar, and very good. There's an important difference about the individual mandate, but it's one of emphasis, rather than actual implementation. But both plans are far from what McCain has put on the table, which simply isn't serious, and would actually do harm.

Labels: InTheNews, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 12:50 AM


 

Dying for Coverage

Thursday, April 03, 2008

California likes to be first at everything. Unfortunately, according to a new series of state-by-state reports by Families USA, we're also first when it comes to deaths due to uninsurance. You can find this sinister stat at Dying for Coverage in California.

They show that:

• Every day, more than eight Californias die due to lack of coverage;
• In 2006, 3,100 uninsured Californians died;
• Between 2000 and 2006, 19,900 uninsured Californians died.

Other macabre findings include the fact that twice as many people died because they were uninsured than died from homicide. The study augments an early report by the Institute of Medicine, which found 18,000 Americans die annually because of uninsurance.

Why do people die for lack of insurance? Let's see -- in a generic nutshell: They're afraid to go to the doctor because it will cost money. They don't get the proper tests done to make sure they don't have cancer or chronic disease. They don't get the proper prescriptions filled for asthma or diabetes. They get sicker. They feel awful, but are too afraid to seek help because of the cost...then it's too late.

So what to do about this?

Well -- first, we wait about 10 months, according to U.S. Representative Pete Stark of California on a conference call releasing the report this morning. Specifically, we wait 291 days give or take a few hours and minutes to be exact for the departure of our sitting president, who Stark says is the “one individual in the U.S. who has done more to disadvantage people …particularly those with low incomes.’’ Specifically, with respect to regulations on who can qualify for Medicaid (Medi-Cal), expansions of children’s insurance, government negotiation for prescription drugs – you name it.

Next, we laud the seating of either (in no particular order) him or her. And then we see if the federal goverment stops being a hindrance to state efforts to provide universal coverage to children and expanded access to low-income families and adults. We'll have issues with him and particularly his health plan, which would atomize the health insurance market and to essentially raise taxes -- against his promise to do such -- for every American who receives coverage through work.

Then, we get back to work.

Labels: PresidentialCandidates, Research, Uninsured

posted by Hanh Kim Quach | Permalink | 11:05 AM


 

Beyond HillaryCare

Friday, March 28, 2008

Sen. Hillary Clinton said in The New York Times today that she wanted to cap health insurance premiums to no more than 5 or 10 percent of income. The statement gives a bit more specificity to her universal health care plan. Obama has also supported the capping of insurance rates, though without putting a number out.

I like that she is talking about tying the cost of health care to income. As we in the advocacy world know -- and too many consumers have experienced -- health care costs are extremely regressive and it's smart to begin introducing the public to that connection.

That said, we also need to begin introducing the concept of capping out-of-pocket costs as well, something that was not included in the story. Cheap plans that cost about $150/month or less are abundant, meaning coverage would cost about 6% a year ($1,800/year) for a person earning $30,000 a year. The problem is that they cost a lot to use.

Office visits aren't covered until the deductibles are met (or limited office visits are available.)
Prescription drugs aren't covered. If they are, brand name drugs aren't. Neither is maternity. Deductibles range from $2,500 to $5000. Out-of-pocket maximums, for one person, could be up to $8,000.

True, not everyone spends up to the out-of-pocket maximum, but in order to get any kind of value out of health coverage, a person would need to meet the deductible. That would mean that person earning $30,000 a year, who meets their deductible on such a plan would be spending 20% of their income on health care. That's a lot.

What's even worse is if you had an unexpected medical emergency, and had to spend up to the out-of-pocket max, that would be about one-third of a $30,000-a-year income. Not fair.

In California, we have spent a lot of time talking and thinking about the affordability of coverage -- both to buy and to use. In AB8, the legislation that the governor vetoed last fall, the affordability limit that we liked was that families that earned less than 300% of the poverty level ($63,600 for a family of four) would have both premiums and out-of-pocket costs capped at 5%.

For ABx1 1, we took a different approach. Families with incomes up to 400% of poverty ($84,800 for a family of four), would spend no more than 5.5 percent on premium. This premium was pegged to a plan that -- while having a $2,500 deductible -- also included “prescription drugs, physician visits, and preventive services, including the services to manage chronic conditions, outside of the deductible. ''

Increasing health care costs are a real thing and is scary. Ignoring out-of-pocket costs as part of that equation would be ignoring the fastest growing part of health care and that needs to be part of the policy discussions.

Labels: Affordability, InTheNews, PresidentialCandidates

posted by Hanh Kim Quach | Permalink | 10:19 AM


 

In McCain's small universe

Monday, March 24, 2008

Kudos to Prof. Tony Sheppard at CSUS, whose careful reading of the newspaper leads us to this story about McCain's recent doctor's visit and cancer screening.

The offending comment:

"Like most Americans, I go see my doctor fairly frequently."

Of course, he can. As a member of Congress, he has access to fancy health coverage through the federal government, which pools together millions of federal workers and provides a really impressive array of options.

For health advocates, though, this off-the-cuff comment belies a deeper concern: Sen. McCain's lack of empathy and understanding for what Americans face is startlingly scary. Because he believes that most have "fairly frequent'' access to the doctor, he sees nothing wrong with his health proposal, a scheme that would cause more people to have worse coverage and bear increasing costs to stay healthy and productive.

For 47 million Americans who lack health insurance and countless others who have inadequate coverage through high-deductible health plans or other products of that ilk, seeing a doctor "fairly frequently'' is a fiction. And given that approximately 2 million more Americans became uninsured annually every year since 2000, we can only expect that number to grow.

If you're uninsured, or have inadequate health coverage, and you're forced to foot 100 percent of the bill to see a doctor - you're not going to go. "I'm healthy; I don't need a mammogram; I don't need a colonoscopy?'' many rationalize. The evidence is there: uninsured patients spend less than *half* the amount that insured people do on health care, according to the Institute on Medicine. Specifically with regard to doctors - 71% of Americans with insurance see a doctor annual, versus 41% of those with no insurance.

Not getting medical care isn't just a problem of the uninsured. Patients who have inadequate coverage are twice as likely to either delay or avoid getting health care because of cost, and far less likely to follow treatments for chronic conditions such as arthritis, high cholesterol or hypertension, according to the 2007 EBRI/Commonwealth Fund survey. Again, specifically with regard to doctor visits -- those with inadequate insurance are nearly twice as likely to avoid seeing a doctor or specialist because of the cost.

This is what we'll be treated to under a McCain health care plan, where employers will be encouraged to dump their workers into a less regulated and less efficient, more expensive individual market to fend for themselves, and where consumers are encouraged to buy high-deductible health plans. Sen. McCain's remark may have been flippant, but shouldn't be ignored.

Labels: InTheNews, PresidentialCandidates, Republicans, Underinsurance

posted by Hanh Kim Quach | Permalink | 2:16 PM


 

More on the McCain health plan...

Wednesday, March 05, 2008

Well, last night's primaries didn't resolve anything, at least on the Democratic side. Senator Obama has a lead in delegates, while Senator Clinton has new momentum.

The Republican contest was officially resolved, with Senator John McCain taking his party's nominations. In a very timely fashion, Jonathan Cohn at the New Republic investigates McCain's health policy platform.

The title says it all: "Mack the Quack: The disaster that is McCain's health policy."

It actually starts out recognizing that McCain was once "in the vanguard of the health care debate," supporting the HMO Patients' Bill of Rights and importation of cheaper prescription drugs from Canada. "But that debate has changed significantly since then, from simply protecting consumers to overhauling the entire system. So the question is: What type of reform would he be willing to swallow in this much more ambitious moment?"

Unfortunately, McCain's plan could actually have us go backwards--having more people try to get coverage in the individual insurance market, where they have the least bargaining power with the big insurers, and which is as a result the least efficient, most expensive way to get coverage.

As Cohn points out, someone with McCain's medical history would not be able to buy coverage on the individual market, because his skin cancer would be a "pre-existing condition."

Cohn notes that McCain's subsidies don't have any proposed financing to back them up, unlike the Clinton and Obama plans, and makes other comparisons with his likely rivals. He even compares their ideas pay-for-performance plans to improve the quality of care.

One note Cohn doesn't make. One hard-right aspect of McCain's plan (McClintock is sponsoring a similar proposal in the California Senate) that hits home to Californians is to allow insurers to sell across products across state lines. In effect, this eviscerates state consumer protections, including the relatively stronger oversight provided by California, since insurers would all go to sell from a state that provides little or no protections. Imagine trying to complain to the Alabama Department of Insurance about being denied for coverage.

McCain, undoes the goodwill he garnered being supportive of some consumer protections (as Cohn indicates) as a legislator with his proposals of what he would do as an executive.

Labels: InTheNews, PresidentialCandidates

posted by Anthony Wright | Permalink | 1:28 PM


 

So much for a truce...

Wednesday, February 27, 2008

Jacob Hacker--soon to be at if UC-Berkeley--may have been someone who helped advise the Democratic candidates on their health care plans, but they didn't listen to his LA Times op-ed yesterday asking for a truce on the question of an "individual mandate."

They spent 16 minutes of their Ohio debate last night on the differences of their health care plans, mostly on the individual mandate. As Hacker says, it's not the central benefit of either of their health plans. Rather, it's the ability to make coverage more available, affordable, and automatic through group coverage.

In their debate, they are arguing over details that neither of their plans currently spell out.

Obama is right to take umbrage at Clinton's suggestion that his plan isn't as universal. It would certainly get to 95%+ coverage, the standard of most industrialized nations with "universal" health care. The Obama and Clinton plans are remarkably similar in how it expands coverage, especially with regard to new subsidized public program expansions, new opportunities and automatic enrollment in coverage at work, and a new public coverage option.

Obama is also right to say that the real problem is not that people don't want coverage--it's that it is not available or affordable, and the so-called "free rider" problem largely resolves itself. Only 2% of Californians are uninsured yet over the 400% of the federal poverty level, and half of them are under $60K for an individual, or $125K for a family of four.

Clinton is right to be upset at the Obama's mailers than are suspiciously similar to "Harry and Louise" ads of 15 years ago, and specifically the contention that she would require people to buy coverage, even if it wasn't "affordable." Her plan specifically would cap the amount that people would be required to pay at a percentage of their income. It doesn't say the specific percentage, so perhaps they might disagree on the definition of "affordable," but right now there's no way to know.

As a critique, Obama also mentions the Massachusetts plan, which had enforcement where people were required to pay a fine is they were uninsured, but still wouldn't get coverage. But the Clinton plan doesn't specify that type of enforcement: In California's AB x1 1, the proposal was not to have fines, but merely to automatically enroll people in coverage--and then consumers would have to pay the premium, like any other bill, but they would also have the benefit of coverage.

So how about a truce? The individual mandate proponents have a point that everybody needs to contribute to the health care system in order for it to work best. The opponents are correct that any contribution needs to be affordable, and as such scaled to income. While it would be preferable to collect these contributions through a progressive tax based on income, it could possibly be done privately through a requirement to get coverage, but then additional protections are needed: some assurances of the benefits and cost-sharing, the value of group coverage, and yes, an overall structure that provided assurances that coverage is available, adequate, affordable, and administratively simple. If the proponents say that part of the benefit of an individual mandate is to make the government more responsive and accountable to ensure that people can access coverage, then such responsiveness should be built into the proposal at the beginning.

Obama says he's willing to do a requirement for children because that infrastructure of Medi-Cal and Healthy Families/SCHIP is largely already there. Clinton promises to have that infrastructure in place before her mandate kicks in for adults. Obama said he would consider a mandate for adults.

What are they arguing about?

Labels: IndividualMandate, PresidentialCandidates

posted by Anthony Wright | Permalink | 1:29 AM


 

Moving beyond Mandates

Tuesday, February 26, 2008

Two interesting pieces in today's news on mandates.

First, California Insurance Commissioner Steve Poizner is dropping his ballot effort, which would have punished drivers without car insurance by allowing police to seize the license plates (and possibly impound) these drivers' vehicles.

Instead, he says, "One of the key problems with why people don't buy auto insurance is a lot of people who come from low-income families believe they can't afford it.'' So, he's going to focus on expanding the state's Low Cost Auto Insurance program.

BINGO.

In spite of California's mandate to obtain car insurance, approximately 14% of drivers remain uninsured, and rates continue to rise. The comments posted about this story about auto insurance refer to high costs -- not whether drivers feel like they're being put upon for being forced to buy insurance. They just want it to be affordable -- just like in health care.

This brings me to the second piece, which is "The Great Risk Shift'' author Jacob Hacker's piece in the LA Times about Obama and Clinton's bickering over to have -- or to not have -- mandates in health plans.

In fixating on mandates, they ignore the really key elements of their plan -- expanding group insurance through expanding public programs, employer-sponsored coverage, and a public insurance pool, which can negotiate for lower (read: affordable -- what Americans want) insurance premiums on the public's behalf.

Even more problematic, it is takes up energy and diverts attention away from combatting the seriously bad "YOYO" (You're On You're Own) ideas, which propose to do the opposite -- having everyone pay for their own health coverage in little silos, rather than pooling risk.

Hacker includes an individual mandate in his plan, but makes the calculation that Poizner does: the issue isn't the mandate (or some other required contribution), it's what you do to make it affordable. That's the debate for the general election.

Update: Here is Ezra Klein's take on Hacker's piece.

Labels: IndividualMandate, InTheNews, PresidentialCandidates, YearOfReform

posted by Hanh Kim Quach | Permalink | 12:02 PM


 

Cost containment bullets...

In the holy grail of cost containment, I've always thought that there isn't one "silver bullet," but there is a list of policy reforms (here's the Health Access one-pager) that can each bring down health costs somewhat, but that taken together, the savings over the long term could be significant.

Some of these reforms are ingrained in comprehensive health reforms: the negotiating power of large purchasing pools, the global budgeting of a single-payer system, or just the preventative aspect of getting everybody insured, and the reduction of the "hidden tax" of having the uninsured. Other elements, such as rate regulation, information technology, transparency of cost and quality, or encouragement of "best practices", are proposals that can be stand-alone, or part of broader reforms.

Joe Paduda at Managed Care Matters seems to have a similar philosophy on cost containment, and a similar list. In his post, he also goes through each idea, how Obama and Clinton fare in their proposals, how effective he thinks each strategy would be.

It's a pretty good and fair assessment, even if I might quibble on details. There are real cost containment elements in the Obama and Clinton plans: none are silver bullets, but together they can make a real difference.

Labels: CostContainment, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 12:57 AM


 

Wonking and blogging...

Thursday, February 21, 2008

The new Health Wonk Review is up at GoozNews, the often-insightful blog of Merrill Goozner.

The wonkosphere is starting to focus on the McCain health care plan, and wondering if there's any there there. Joe Paduda wonders if McCain is on the wrong side of the issue with the Republican base. Bob Laszewski does his treatment of McCain.

And Ezra Klein traps "no-new-taxes" McCain, by spotlighting the fact that by getting rid of the deduction on employer-based health benefits, McCain's health plan is a de facto tax increase.

Labels: OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 8:46 PM


 

What could be

Wednesday, February 20, 2008

It got good marks! Here's the upshot:

• 99.6 percent of Americans would be covered without requiring the US to spend one extra dime that it isn't already spending on health care.
• $1 trillion would be saved over 10 years (the US currently spends $2.3 trillion annually on health care)
• Businesses who already provide coverage would save $10 billion -- they only have to contribute 6%. Businesses that aren't paying for health care would now be on the hook and share the cost.

Lots of other goodies. Click here for all the links.

Labels: InTheNews, PresidentialCandidates, YearOfReform

posted by Hanh Kim Quach | Permalink | 3:50 PM


 

Healthy experiences for would-be presidents...

Monday, February 04, 2008

So the big news is the election tomorrow.

While we don't endorse candidates, we've commented extensively on the presidential candidates and their various health care policy platforms.

What I am impressed by is how much experience the candidates have with health policy and health reform.

Senator Clinton clearly knows the issue inside and out, from the experience in 1993-4. While there is a debate whether the mistakes of the 1993 Clinton effort were hers or her husband's, it's clear she knows the policy, the politics, and has learned lessons from her previous effort. She kept her interest in health policy issues in the U.S. Senate, and the fact that she has made it a priority despite her previous failed attempt suggests a perseverance that is welcome for such an important fight.

Senator Obama was one of the "go-to" legislators on health policy for my consumer advocate colleagues in the Illinois legislature. He was a leader on issues around the expansions of the Illinois version of SCHIP. When the majority changed to his party, he became the chair of the Health and Human Services Committee, and from there he pushed through the Health Care Justice Act, which started the process to get universal coverage in Illinois--a process that is roughly in the same place as California's effort (regrouping but continuing). He knows the policy and politics of these issues as well. Having been on the front lines of state health policy, he is likely to be very sympathetic to the specific health needs of a large, diverse state like California.

While they have done less to prioritize health issues, even the Republican candidates have some experience on the issue.

Let me be clear: they have pur forward several proposals that consumer advocates oppose--one trope that most of them endorse is to eviscerate state consumer protections, by allowing insurers to sell plans across state lines. (How would you like to complain to the Nebraska Department of Insurance if you were denied care?) While the Democrats want to regulate insurers so they can't deny coverage to those with "pre-existing conditions," the Republicans explicitly reject such oversight.

But the Republican presidential candidates have shown flashes of moderation in support of health reforms, even in areas that have been opposed by President Bush, or the Republican legislative caucuses in Sacramento. Senator McCain supported the long-stalled HMO Patients' Bill of Rights. Governor Romney signed the Massachusetts health reform, including the major public program expansions that now is covering half the uninsured. (He vetoed elements, that by agreement with the Legislature, were overridden.) Governor Huckabee was involved in Arkansas' early expansion of child health care, before SCHIP was created.

So whatever the outcome, it's clear is that the next President of the United States will have more direct experience with health care policy issues than the current occupant. We'll find out more next week...

Labels: PresidentialCandidates

posted by Anthony Wright | Permalink | 11:55 AM


 

Where's your vote...

Thursday, January 31, 2008

Health Access doesn't endorse candidates, but we'll help you analyze where candidates are on health reform as we finish up our comparison in the next day, and compare presidential candidate plans to the ill-fated ABx1 1 legislation.

In the meantime, check out this really cool assessment of candidates at http://www.healthcentral.com/healthcare08/

Labels: PresidentialCandidates, YearOfReform

posted by Hanh Kim Quach | Permalink | 2:42 PM


 

Register and Vote...

Monday, January 21, 2008

Tomorrow, Tuesday, Janaury 22nd is the deadline to register to vote for the Presidential Primary in California, which is Tuesday, February 5th.

There's ballot measures and much more. Health and a lot of other key issues are in play. If you aren't already, please register, and vote.

For more information, go to the Secretary of State's website:
http://www.sos.ca.gov/elections/elections_vr.htm

Labels: PresidentialCandidates

posted by Anthony Wright | Permalink | 2:02 PM


 

The GOP Group of Candidates on Group Coverage...

Sunday, January 06, 2008

In the Republican presidential debate tonight, Dr. Tim Johnson of ABCNews won the section on healthcare, of which none of the candidates had an adequate response.

Dr. Johnson's set-up piece made the point that the Republican plans more perhaps more radical than the Democratic plans, in that they attempted to shift people away from group coverage--largely through the employer-based coverage that people have now--into the individual market, via Health Savings Accounts, etc.

Dr. Johnson further gave facts about how individual coverage is more expensive and less efficient--partially because of administrative costs, the inefficiency of having to sell the products one at a time, the lack of any economies of scale, and the inability of the purchasers to leverage their market power to get better cost and quality. He didn't land the most obvious punch--that many of the Republican candidates, as cancer survivors, would be unable to buy coverage in most states, including New Hampshire (and California), because of their "pre-existing conditions."

It's probably the most important distinction between how the two parties view health care. One direction is to expand subsidized group coverage, through employers, public programs, or even a single-payer system. The other is to shift more people in the individual market, leaving consumers at the mercy of the insurers. Guiliani wanted to shift around 17 million to about 50 million buying coverage as individuals-- I am not sure those 30+ million would prefer that approach.

Romney came the closest to responding, by saying that the Connector in Massachusetts does provide an opportunity for individuals to take advantage of those efficiencies of group coverage. He's right. But then he went on to completely misrepresent his own plan in Masssachusetts. He took credit for the fact that over 300,000 people in his home state now have coverage, but then he made a big point of saying it was "private coverage," which is just untrue. All but a handful of those 300,000 got coverage through the public program expansion for those under 300% of the poverty level.

He mentioned Governor Schwarzenegger's efforts at health reform in California, not as endorsement, but as a way to say that states should take the lead in designing different plans, and suggested that those that do should get federal funding assistance. That's helpful to know. But given how all-over-the-place he has been on his own plan in Massachusetts, I am not sure I would take anything to the bank.

Labels: PresidentialCandidates

posted by Anthony Wright | Permalink | 12:35 AM


 

Caucus night!

Thursday, January 03, 2008

So Obama and Huckabee had a good day in Iowa. What's the news for health care?

Well, as those of us in California face a budget crisis with major health cuts looming, it's interesting to note that the winner of the Republican caucus was a Governor who saw fit to raise taxes when necessary to invest in his state, and support some coverage expansions for children and parents in Arkansas. He has quite a conservative record--and much I would disagree with--but this particular point is something that legislative Republicans in California might want to take a look at.

On the Democratic side, it was clear that the health care was one of the top three issues, with Iraq and the economy. Edwards spent a significant chunk of his speech tonight talking about the uninsured and those denied care by insurers, and deserves credit for coming out first with a broad and comprehensive health reform plan, and setting a benchmark for the field. In his memorable speech, Obama started his issue list with a commitment to health care, and his history in Illinois. And Clinton's commitment is well known. In the end, the candidates had very similar proposals, so there's a little for voters to distinguish on specific plans. And they roughly split the voting public on the question of who would do the best in terms of health care.

But they did have a difference in what they emphasized. I think Obama had a slight edge (34%) to Clinton (30%) not because of the substance of the proposal (which are very similar), but what they emphasized. Clinton attacked Obama on not having an individual mandate and not being "universal" enough, Obama responded not by saying he's against a mandate, but by emphasizing the aspects of his plan that will help people get coverage, especially with regard to affordability.

It goes to my earlier point about the national health reform debate: while health reformers should be upfront about what is need to achieve health reform, we need to focus on the actual help that any reform will provide voters. Rather than get lost in philosophical debates, we need to emphasize what any plan will actually do to make coverage more available, affordable, and administratively simple.

Labels: PresidentialCandidates

posted by Anthony Wright | Permalink | 9:00 PM


 

Lots of areas to debate...

Wednesday, January 02, 2008

My dad was impressed with the New York Times chart this weekend comparing the positions of the various candidates, on a variety of issues.

I thought it was useful, mostly to demonstrate the similarities within the parties, and the large gulf between them. In a chart that small, it doesn't go too much into detail, so the nuances aren't really specified. So on taxes, the Democrats are all for repealing the Bush tax cuts for the wealthy; the Republicans largely want to make them permanent.

On health care, I think the descriptions are less than helpful. They lead the description of the Democratic proposals by emphasizing the mandate on individual to get coverage (and of the Republican proposals their opposition to any mandate).

This is a difference between the Ds and Rs, but its not the fundamental one. The vast majority of voters want coverage, so the issue isn't the requirement to have it: it's what the plan does to break down barriers to get coverage.

The real dividing line is that the Ds want to expand subsidized group coverage, through employers or public programs, and by creating/opening up purchasing pools. They would place greater regulation over insurers, especially with their ability to deny people for "pre-existing conditions."

The Rs say they are "for free-market, consumer-based system," and the Times merely repeats their rhetoric without describing what that means. The Rs largely do not support setting a standard for employer health coverage, or expanding public programs--or the revenues that make the coverage expansions possible. The help their proposals offer, if any, is some tax credits to buy coverage in the individual market--where people can be denied for "pre-existing conditions." Rather than furth