The Obama transition team at http://change.gov is taking comments from the public, especially on health care and health reform. Here's Health and Human Services Secretary-designate Tom Daschle responding to some of them:
As this TV ad is being run in the Washington, DC, area, we're happy to be part of the Health Care for America Now! campaign's effort to keep President-elect Obama to his promise, and his promises:
The recent Jupiter clincial trial revealing that statins like Crestor may help prevent heart attacks, even for folks who would not ordinarily be prescribed the cholesterol-lowering drug, got front-page news.
While this could be an important breakthrough in science, medicine, and health, there are some concerns, encouraged by the . Leave it to Comedy Central's The Colbert Report to provide a counterpoint:
Colbert brings up some of the legitimate critique of PhRMA: that their research is focused more on finding a steady income stream from existing drugs than on new discoveries. “This is a great breakthrough in the battle to find things to prescribe to people who don’t need them...True, the drug costs $100 a month... But that is a small price to pay to not have the heart attack that there’s no way of knowing that you would have had.”
After a clip of Stanford cardiologist Mark Hlatky urging caution, Colbert quipped, “sounds like someone hasn’t gotten enough free Crestor pens.” Health Access California, CALPIRG, California Labor Federation and other senior and consumer groups supported a bill earlier this year to place limits on the drug company giveaways to medical providers, but the active opposition of PhRMA blocked it. Maybe now that the issue has gotten the famous "Colbert bump" (along with the city of Sacramento), we can be more successful in the future.
If the articles (and our sources of information) are right, we start from a vastly improved place from the Clinton era. The then-Chair of the Senate Finance Committee, Daniel Patrick Moynihan, wass openly dismissive of the need for health reform, much less the framework. In contrast, Senator Baucus is proposing a framework very similar to the plan that President Obama ran on, and poured well over $100 million in campaign TV ads promoting.
Both Obama and Baucus plans appropriately focus on expanding group coverage, including expanding public programs for lower-income children and adults, and employer-based coverage in general. It would offer purchasing pools and public coverage options. Both would institute a variety of cost-control measures, and new regulations on insurers--particular preventing them to deny people for "pre-existing conditions." That's good stuff, and a strong platform to start.
Much will be made about the notion of an individual mandate, which was a debating point between Senator Clinton and Senator Obama during the primaries. Clinton was for it; Obama said he wanted to ensure affordability before considering the requirement for adults as well (his plan includes a requirement for children, ). Many have argued that the issue was overblown.
We at Health Access have been skeptical of the individual mandate, but not opposed to the notion that we all--sick and healthy--should contribute to health coverage (as many health reforms, including single-payer, include). Rather, our issues were more about the problems in the inefficient and inequitable individual insurance market that some may be forced into. It was only in the context of expanding group coverage, shrinking the individual market, and placing new subsidies and restrictions, that we and other consumer groups supported AB x1 1, the negotiated deal between Governor Schwarzenegger and Speaker Nunez.
So the real question, in the Baucus plans and others that may come out, is: what help does it provide? Will it leave consumers are the mercy of the private insurers, of the individual insurance market?
In addition to supporting the concept and urgency of health reform, we as consumer advocates can push to ensure that we institute new rules for the private insurers, especially with regard to allowing them to pick and choose who they cover; that we offer new purchasing pools so individuals and employers can better negotiate for the best deal; and provide new public coverage options, as a competitive choice.
Let's look at the details when they come out, but that's what I will be looking for.
Lots of commentators, stakeholder groups, and bloggers are debating whether President-elect Barack Obama has the interest in, or the mandate for, comprehensive health reform.
Some are arguing that economic priorities must come first, that we can’t afford to fix our health care system until later.
Candidate Obama directly addressed this question on October 4th, just one month before the election:
”Now I know that at this moment, when we stand in the midst of a serious economic crisis, some might ask how we can afford to focus on health care. Well, let’s be clear: the rescue package we just passed in Congress isn’t the end of what we need to do to fix our economy – it’s just the beginning. Because the fundamentals of our economy are still not strong – contrary to what Senator McCain says. And we’ve got to address those fundamentals – and address them right now.
In other words, the question isn’t how we can afford to focus on health care – but how we can afford not to. Because in order to fix our economic crisis, and rebuild our middle class, we need to fix our health care system too.… So it’s clear that the time has come – right now – to solve this problem: to cut health care costs for families and businesses, and provide affordable, accessible health insurance for every American.”
It's been a historic night. Now, the real work begins. But here's a few thoughts, and then more after some sleep.
For the cause of major health reform and coverage expansions, the election of President-elect Barack Obama makes me very hopeful:
1) He and Senator Biden endorsed the Health Care for America Now! principles, in support of a guarantee of quality affordable health coverage, and against leaving consumers alone at the mercy of private health insurers. Along with over 125 members of Congress, he has committed to make health reform a top priority, and under the right principles.
2) He put his money where his mouth is, spending over $110 million of his campaign resources on advertisements around health care issues. When voters gave him this mandate, they did so partially because they support health reform, and the type that Obama was talking about.
3) Health care is so important to consumers that any major change in our health system requires a certain level of trust that reform is possible, and positive. In a post-Katrina world, Obama's core message, against cynicism and the appeal that we all have a shared future, together, is as important for the cause of health reform as any policy detail.
4) The increased margins of his party in the House and Senate will help. So will his impressive showing in previous "red" states, giving him strength and leverage with moderate Democrats and Republicans. For example, he won Iowa easily and came excruciatingly close in Montana--the home states of the two leaders of the Senate Finance Committee (Grassley and Baucus)--perhaps the most important hurdle for health reform in the legislative process. He can use his mandate for health reform in those states.
5) Finally, we now have the ability to pursue reform not just at the state, but federal level. And for those of us committed to state-level reforms, it looks like we will have a partner, rather than an obstacle, at the federal level.
Also, FYI, in other good news, Arizona narrowly defeated Prop 101 (50-50, by only a few thousand votes) the anti-universal health care intiative, that would have prohibited health reforms like that of Obama, Schwarzenegger-Nunez, or single-payer. But that's too close.
There's lots of races, from the presidential to Congressional, in state Senate to Assembly seats, where health care issues loom large. It could have been much more so.
Let's remember that the stalling of AB x1 1 earlier this year, in January, was not the final hurdle. Even if the negotiated health reform plan between Governor Schwarzenegger and Assembly Speaker Nunez had passed the legislature, it was entirely contingent on a companion ballot measure with the passing on the ballot... tomorrow.
How would that measure, which included the financing for the health reform, have fared? It's hard to tell.
Some believed this was the best opportunity in a generation to have health reform up on the ballot, given the record turnout expected tomorrow, especially with younger, lower-income, community of color, and first-time voters. All these groups went strongly for Prop 72 in 2004.
There's also the notion that AB x1 1 had a similar framework to the Obama plan (although there are differences in the details). The case could have been made to the majority of California voters expected to vote for Obama to also vote for his health plan.
At the same time, the ballot measure to fund AB x1 1 would have had lots of well-funded opponents, from Blue Cross to the California Restaurant Association. Both sides could claim credible spokespeople within the health care world, and would attempt to use the budget deficit and economic recession in their talking points, for and against the measure. It is a crowded ballot, with other measures (like Props 4 & 8)--not to mention the Obama campaign--getting lots of attention from voters, volunteers, and contributors.
It's unclear what the fate of a health reform proposition would have been. What I do know is that the last two efforts to expand coverage on the California ballot have both gotten within two percentage points: the expansion of employer-based coverage, Prop 72 in 2004, at 49.2%, and a tobacco tax to fund children's coverage and other care, Prop 86 in 2006, at 48.2%. The results in these recent contests were too close not to think there won't be new attempts in the future.
Ezra Klein at The American Prospect lists the reasons why employers seem to be wedded to our system of employer-provided health coverage, and his commenters add on. For those who support a shift to either a single-payer system or an "you're on your own" individual market-based system, it's worth considering.
Further puzzling all those cubicle dweller procrastinating on the Web by looking for tidbits of election news, Karen Tumulty at Time.com's Swampland graciously responded to my post from yesterday, where I generally agree with her, but take issue with a characterization that some young people might "choose" to go uninsured.
As she writes:
I think we are making the same point, but coming at it from different directions. Wright is absolutely correct that young people are disproportionately uninsured, and for the reasons he says. But that's true under the current system as well.
Here's what I meant with my suggestion that McCain's plan might actually encourage people to drop their coverage voluntarily. Say you are 23 years old and in good health, and lucky enough to be working for an employer who provides you health coverage. Under McCain's plan, the amount that your employer spends on your health insurance suddenly gets added to your taxable income. McCain provides a tax credit to offset that, and if it covers your additional tax liability, the chances are you would continue to take coverage under your employer's plan. But if you live in a state where health care costs are high, or your employer has a particularly expensive plan (because the benefits are great, or because the workers in your company are sicker, or older, increasing the costs of their coverage), the tax credit might not cover it. In that instance, you would be tempted just to drop it and take your chances on not getting sick.
In economic terms, that would be a completely rational decision. Unless you get in a car accident. And the departure of a worker who is a relatively good risk would leave your employers with a workforce that is, on average, even more expensive to insure--which might ultimately force the company to drop coverage for everyone.
And here's my agreeable response, cross-posted from Swampland's comments section.
Much thanks, KT, for the link, and the dialogue, and your evident and appreciated interest in health issues, in all their complexity. I actually agree with you: the McCain plan will leave some young (or more relevantly, newer, entry-level, and lower-income) workers without employer-based coverage, and uninsured as a result.
* I agreed with your earlier point, too. My beef was more with Gov. Romney, who made inaccurate assumptions about this segment of the uninsured. Instead of seeing the additional barriers to coverage they face and thus trying to make group coverage more available to young workers, like bolstering employer-based coverage, he put the burden on the individual to sign up, as if that was the main problem. (In fact, he even vetoed the small fee on employers who didn't provide health coverage to their workers--the legislature has to override his veto to pass that part of "his" health plan.)
* Again, young people take up employer-based coverage at roughly similar rates as older folks. Without the group rate and employer subsidy, younger folks with lower-incomes find coverage on the individual market not affordable, either the premium, or the out-of-pocket costs.
* A number of the comments (cliff, calkate, kevpvp) here raise another key point: Health coverage should not just *available* and *affordable*, but *administratively simple*. Another reason why employer-based coverage is so prevalent (and largely taken up, by young and old workers alike) is that it is easy to sign up at work. In contrast, trying to understand and navigate the individual market is a nightmare, and takes a lot of pro-active thought and action. Another reason why the individual market is least efficient, most expensive way to get coverage.
* There's been a lot of attention to behaviorial economics, and commentor "chucksname" referred to 401Ks. In fact, the research suggests that a major factor on enrollment is not as much income as simply whether signing up for a 401K plan is automatic or not, or if the choices are too numerous or complex.
* In California, we have sought reforms to make the individual market more transparent and understandable, to allow for apples-to-apples comparisons, etc. But the real lesson is to focus expansions on group coverage instead, either through public programs or employers.
As the article points out, Baucus has a mixed health record, siding with Republicans on some issues like Medicare Part D (which most consumer groups, including Health Access California, opposed) and President Bush's first tax cut, working closely with the ranking Republican, Chuck Grassley. Yet he led the fight against the privatization of Social Security, and for SCHIP reauthorization and Medicare payment reforms earlier this year.
The article ends with optimism:
In June, Baucus assembled his whole committee in the Mumford Room of the James Madison Building for a daylong health-care conference called "Prepare for Launch." The event began with Baucus standing before a projection screen that showed a space shuttle firing its way into orbit. "I think that video captures the essence of what we're trying to do today," said Baucus proudly. "Which is prepare for the launch of health reform."
In this, he is proving the opposite of the finance chair who last presided over a major attempt at health reform: Daniel Patrick Moynihan, who aggressively opposed Clinton's health-care plan in 1994. Moynihan went as far as to appear on Meet the Press to accuse Clinton of using "fantasy numbers" and declare that "there is no health-care crisis." By contrast, Baucus has spent the last year holding a series of hearings meant to convince his committee and the country that there is a health-care crisis. He's staffed up his health-policy team, consulted with outside experts, and held individual meetings with his members. And if Barack Obama wins in November, Baucus, unlike Moynihan, is likely to enjoy a good relationship with the incoming administration. The Obama campaign's chief of staff, Jim Messina, was hired out of Baucus' office. "If you asked what would Baucus be doing this summer," says one liberal health reformer who's long been skeptical of Baucus' commitment to the issue, "I could not have mapped out a better strategy for him to follow. He's doing it."
Baucus seems interested and invested in health reform, but it is unclear on what type of reform. He does have moderate, if not conservative, tendencies. If Senator Obama wins, he may be especially pushing for a win, or at least a good showing, in Montana. To the extent that Obama does well in Montana (and Iowa), he can show a mandate for his health plan to Baucus (and Grassley) in their home state.
Changing the tax treatment wouldn't hurt the employer-sponsored system and would allow more of the uninsured to buy their own coverage, they say. Also, his advisers say a McCain administration would keep an eye on the credit to make sure it didn't lag behind the cost of coverage, while also working to lower the rate of medical inflation.
Younger, healthier workers likely wouldn't abandon their company-sponsored plans, said Douglas Holtz-Eakin, McCain's senior economic policy adviser.
"Why would they leave?" said Holtz-Eakin. "What they are getting from their employer is way better than what they could get with the credit."
The quote is right. If we discourage employer-based health coverage by removing the current tax advantages, some employers will drop coverage (there's been an ongoing trend of employers scaling back coverage & reducing eligibility, even without a change in the tax incentives.) This will leave their workers to fend for themselves in the individual market, where coverage is more expensive and less efficient.
The McCain tax credit will not make up the difference of either the employer's contribution to health care, or the benefits and negotiating power of group purchasing.
In short, what people get from their employer is "way better" than what they will get with a credit to buy on the individual market--whether in terms of out-of-pockets costs, benefits, or all-around value. (Here's Jon Gabel's study on the California HealthCare Foundation website to provide the appropriate apples-to-apples comparison.)
McCain's plan actively seeks to push people from group to individual coverage, which seems to wrong way to go. And apparently, his advisors seems to know this. This is one of the major differences between the McCain and Obama health plans.
ADDENDUM #1:
There's an additional "adverse selection" argument, which is that some workers might be tempted to leave their employer-based health coverage to buy in the individual market (which is less expensive for younger, healthier workers). If too many do, this will leave older, sicker workers in their group plans, causing the the employers' premiums to go up, leading to a "death spiral," causing the employer to drop coverage.
If this was only about removing the tax benefits from employer-based coverage, Holtz-Eakin would be right, although not to credit of the McCain plan. Even still, an employer would have to offer pretty skimpy benefits (high deductibles, a large share-of-premium, annual caps) for somebody to think they can do better on the individual market.
Some critics of health reforms (from SB2 to AB x1 1 to the Obama plan) suggest that purchasing pools would be negatively impacted by adverse selection, making them cost more, as opposed to being able to negotiate down the cost of health care using its bargaining power. And that's been the case for some voluntary small business purchasing pools. But it's a different story for subsidized pools, where even the youngest, healthiest person will stay in the employer group to get the implicit employer subsidy. As a result, the employer group then has the negotiating leverage to negotiate for all their workers, and the insurer has a much harder time just trying to cherry-pick only the customers they want.
The tax credit would have to be significant (and expensive) to allow for this; and so the policymakers would have a perverse incentive to make the credit less attractive. So the McCain plan is less vulnerable to this issue, but only by creating a much more obvious problem: giving many workers worse health coverage than they have now.
ADDENDUM #2:
Karen Tumulty at Time.com's Swampland take the argument another step, and suggests that young, healthy people will just become uninsured. She's right, but for the wrong reason. She suggested that young people would "choose" to go uninsured, as Gov. Romney suggested. As I wrote in her comments section:
Much of the differential in insurance coverage in age groups is accounted for if you hold for income and job-type. Think of the young person just starting their career, or working for McDonald's or Wal-Mart.
In other words, young people will become more uninsured under the McCain plan because they are more likely to be the entry level or lower-income workers impacted first as employers further drop coverage. Some might buy coverage with the tax credit, but many won't be able to afford the difference, some would be denied for pre-existing conditions, and some would find that what they could buy with the tax credit (a $5,000 deductible plan, say) doesn't make sense for a young person with no assets, who would go into bankruptcy before the coverage kicks in.
Let's not blame the victims. The plan is still bad, just in a different way.
The Wall Street Journal health blog reports that Barack Obama has $113 million -- or 68% of his total ad budget -- on health care-related ads. Add to that $13 million in drug company spending in favor of SCHIP (children's health coverage) and Health Care for America Now's ads advocating health reform (not John McCain-style reform) and we have an electorate with a higher consciousness of health issues, and fertile political environment perfectly primed for next year's fight.
It's the word that single-payer opponents often use to scare people from supporting the idea.
In "those countries" with "socialized medicine,'' people have to "wait in line'' to see a doctor (kind of like we do here. Of course if our Timely Access to Care legislation from 2002 could actually ben enacted...ahem).
Also, in countries where the "government runs" things, you may not be able to get the care you need because a nameless, faceless bureaucrat will stand in your way. (Again, that's kind of like here in the US. But because we're #1, we have lots of choices when it comes to being denied care. A 'private insurer' can then deny you care. You can be uninsured and be unable to afford care. Or, if you have health coverage your private insurer can also retroactively cancel your coverage.)
In California, lawmakers have argued the same thing on many occasions. In one hearing, Assemblywoman Audra Strickland, a Moorpark Republican called universal healthcare a “Las Vegas buffet,’’ where “everyone eats for the same price; everyone waits in the same long lines. Some of those more sought after foods.... some people get them, some people don't.”
Then, rationing occurs, she explained at another hearing:
“Preferential treatment – that’s a big problem that happens when the government gets to decide things,’’ she said. For instance, a sports athlete with a torn rotator cuff could jump in line ahead an older person who had the same injury.
Opponents of universal healthcare, however, fail to see -- or acknowledge that the current system also rations -- those who can afford healthcare and "Cadillac coverage" get care. Those who can't don't -- and often suffer mightily. Rationing would become ever more pronounced under McCain's healthcare plan.
From the debate Wednesday night:
Now, 95 percent of the people in America will receive more money under my plan because they will receive not only their present benefits, which may be taxed, which will be taxed, but then you add $5,000 onto it, except for those people who have the gold-plated Cadillac insurance policies that have to do with cosmetic surgery and transplants and all of those kinds of things.
A kidney transplant, so that a person can live, is "Cadillac" coverage? Maternity benefits, so that a woman can receive prenatal care and have a healthy newborn is "Cadillac" coverage?
McCain and his supporters cloak his healthcare plan in patriotic ideas like "choice'' and the ability for Americans to "decide'' what's best for them and their families. The fundamental problem with this is, is that there is no choice. The market has already "chosen'' for us -- and that choice is profits over over people.
On September 30, Governor Schwarzenegger, who supports John McCain for president, vetoed AB2, a measure to help shore up California’s high risk pool—even though high risk pools are a key concept in John McCain’s health proposal.
California’s high risk pool serves about between 7,000 and 9,000 people, a small fraction of the medically uninsurable population under the current system. Academic experts tell us that 3%-5% of the under-65 population is uninsurable while insurance company actuaries say the right range is more like 7%-10%. California currently has 2-2.5 million people in the individual market so that means that one rough estimate of the number of uninsurable Californians would be 200,000-300,000 people, literally twenty or thirty times as many as currently get coverage through California’s high risk pool, MRMIP.
We know the McCain plan would increase the number of people in the individual market substantially. The new estimates by the Economic Policy Institute say that McCain plan would double the number of people in the individual market in California, adding 2.5 million people. That means that the number of uninsurable Californians would climb to a half million or more. Where on earth are we going to get the money to subsidize coverage for these Californians? Budget deficit. Fiscal meltdown. Stock market tanking. We can barely find the money to help 9,000 medically uninsurable Californians buy coverage: how will we help fifty times that many?
Or maybe the McCain plan is actually what it seems—health coverage for the healthy and the rest of us are just out of luck.
And as for Governor Schwarzenegger’s plea that we should not fix the high risk pool absent comprehensive reform, we ask what reform plan is that? The plan of the presidential candidate he supports? Or the very different plan (or should we say, plans) he supported in 2007? As we look forward to 2009, both in California and nationally, we keep in mind the hundreds of thousands of Californians who cannot buy health insurance at any price.
Health Access has never endorsed a candidate in our 20-year history, and as a nonpartisan organization, I am refraining from posting some of the health-related ads from the presidential campaign.
I will say that I am pleased that there *are* health care ads, and that health care is an active point of discussion in the campaign.
But this ad is from a Kansas Senate race, that we here in California can only sit and watch, and chuckle:
McCain's Plan IS a Tax Increase on the Middle Class
Friday, October 10, 2008
Ron Brownstein, a journalist who pays special attention to health policy and politics, writes today on the McCain plan. He says rightly that the erosion of risk sharing is one of the worst features of the plan—that it encourages younger, healthier workers to leave employment-based coverage for the individual market, thus destabilizing the more efficient risk pooling of employer coverage. Brownstein also rightly says that “the bedrock goal of Obama’s plan is to reinforce sharing of risk and cost between healthy and sick, young and old.”
But Brownstein says that the Obama’s campaign’s description of the McCain plan as the “largest middle-class tax increase in history” is just “flat wrong”. Usually Brownstein makes a lot of sense but this time it is Brownstein that is wrong.
The McCain plan would say that if you get health insurance on the job, you would have to pay income taxes on the value of what your employer contributes to your health insurance. And until a few days ago, the McCain folks seemed to be saying it would also be subject to payroll taxes like FICA (Social Security and Medicare taxes). It was only after Obama called this the largest middle class tax increase in history that the McCain folks clarified (or shifted) their position so that employee health benefits would only be subject to income taxes.
Brownstein cites the Tax Policy Center, another outfit we have a lot of respect for, to prove his point that the McCain plan is not a tax increase. Economists seem to be overlooking two key points:
First, Americans, especially those below median income, have faced wage stagnation in the last decade. The notion that somehow employers will make up the difference if health benefits are taxed is just not plausible to many real people given their actual experience in the real world of work. Economists assume that health benefits are just part of compensation and that if health benefit costs decline, wages will increase. That may be true for the upper end of the labor market but is it true for most of the middle class that has faced stagnating wages and declining benefits? Or will it be a new tax with no compensating increase in income?
Second, for many of us, a tax credit of $5,000 for a family is nowhere near enough to cover the cost of coverage. If the average job-based premium is now almost $13,000, there are lots of places in this country where health care costs are higher than average. And there are lots of people for whom premiums are higher than average---if you are over 40 or 45 or if you have health conditions like high blood pressure or asthma or diabetes or if you are overweight. In 45 states, insurers price premiums higher based on age and health status. The McCain plan not only does not fix that problem, it encourages insurers to do the worst version of that because it allows insurers to compete nationwide, sweeping aside whatever protections advocates have won in the various states.
Sen. Obama says that with one hand the McCain proposal gives you a tax credit but with the other, it imposes taxes on your health benefits. That is true. And what is also true is that many people will not come out ahead on the deal—and that is even before the implosion of employer-based coverage that not only Brownstein, but the US Chamber of Commerce and other business groups consider likely.
Big differences between them, and bigger impacts in California
HEALTH ACCESS CALIFORNIA ALERT Friday, October 10, 2008
HEALTH PLANS OF PRESIDENTIAL CANDIDATE WOULD HAVE SIGNIFICANT IMPACTS ON CALIFORNIANS' COVERAGE
* Under McCain Health Plan, Over 2.4 Million Californians Would Lose On-the-Job Health Benefits
* New reports reveal McCain's plan that would strip away consumer protections, raise taxes, and leave many California families to fend for themselves at mercy of insurers * New chart shows Obama’s framework similar to Nunez/Schwarzenegger proposal, with expansion of employer coverage, public programs, and insurer oversight
California, because of its specific demographics and policies, will be more acutely impacted by the health proposals of the two presidential candidates, according to new information released today by Health Access California, the statewide health care consumer advocacy coalition, and Health Care for America Now!, a national campaign to win quality, affordable health care for all Americans.
Risks of the McCain Plan:Health Access California and Health Care for America Now released two new reports from the Center for American Progress Action Fund and the Economic Policy Institute which find that 2.4 million Californians would lose employer-sponsored health insurance under the McCain health care plan. The reports conclude that McCain’s health care plan would accelerate the deterioration of employer-sponsored benefits by both removing current tax incentives and, at the same time, taxing employee benefits as if they were salary.
In California , Senator McCain’s plan would: * Threaten the coverage of over 17 million people in California who receive health benefits through work. The Economic Policy Institute projects as many as 2.4 million could lose their job-based coverage. McCain’s plan eliminates the employer health care tax benefits that enable many businesses, especially small businesses, to provide group insurance to their employees. * Put at special risk coverage for the 6.2 million non-elderly people in California struggling with diseases like cancer and diabetes who are now covered through their jobs. Under McCain’s plan, insurance companies would be free to “cherry pick” only those individuals for coverage who do not have costly health conditions and avoid state regulations that keep health care accessible and affordable. * Raise taxes on the health insurance benefits paid by millions of California families. A typical California family could pay almost $1,300 more in taxes by 2013 if McCain imposes both income and payroll taxes on their health coverage.
At least one in 13 people would lose his/her employer-sponsored health insurance benefits and be forced out into the private insurance market where premiums are more expensive and coverage is less comprehensive. Anyone with a pre-existing condition – as defined by the insurers themselves – could be denied coverage altogether.
Comparison with California Proposals: Some of the provisions of the plans of the two presidential candidates, Senator Barack Obama and Senator John McCain, have been extensively discussed in California . As indicated by a chart prepared by Health Access California, Senator Obama’s plan follows a very similar framework as AB x1 1, a plan negotiated between Speaker Nunez and Governor Schwarzenegger, and the plan’s antecedents in the legislature.
The provisions of Senator McCain’s plan has gotten less state-level attention, except for one bill, SB x1 16 by state Senator Tom McClintock, to allow insurers to sell across state-lines, and thus avoid state oversight and consumer protections.
California Consumer Impacts: In each of the three ways that consumers get coverage, the McCain and Obama plans have radically different strategies, each on with significantly different results:
* On Employer-Based Coverage: Just around half of Californians (nearly 18 million) have employer-based coverage, but Californians are less likely to get job-based benefits than in the rest of the country. · The McCain plan would tax health benefits offered by employers, and offer a tax credit instead for those on the, individual health projects. This would result in the 1.3 to 3.3 million Californians losing their health coverage through work, according to EPI. · Given the lower expectation of on-the-job benefits in California , there is fear that the state is reaching a “tipping point” in some industries, where if more leading employers drop coverage due to different tax incentives, that would force all competitors to follow. · The Obama plan would bolster on-the-job benefits by setting an as-yet-determined minimum requirement for employers to contribute to health care for their workers, and also provide financial assistance to small business, and new purchasing pool options for all employers. * On Public Programs: Under a third of Californians--over 10 million--have public program coverage: over 6.6 million low-income children, parents, seniors and people with disabilities through Medicaid (Medi-Cal in California ), and another remaining 4 million seniors and people with disabilities in Medicare. There is another 800,000 children in SCHIP (Healthy Families in California ). * The McCain campaign recently changed the health plan, saying it would require a $1.3 trillion cut to Medicaid and Medicare. (This was prompted by the McCain’s plan shift, in saying that the plan would eliminate only some, rather than all, of the tax deductions for employer-based care.) * Such a cut to Medicare and Medicaid would mean significant reductions in benefits or access to medical providers for these children, seniors, and people with disabilities. It also would force additional cuts at the state level. California has already made significant cuts to Medicaid due to the current budget crisis, and such a cut at the federal level would compound the budget problem. * The Obama plan would fund and expand programs like Medicaid and SCHIP: California would be first “in line” to take advantage of resources that might be available, especially since our state and county efforts already have more expansive eligibility. In short, public program expansions at the federal level will allow California to claim additional federal marching funds.
* On the Individual Insurance Market: Roughly 2 million Californians-- less than 10 percent—buy coverage as individuals, but it is a bigger share of the population than other states. As a result, Californians are more likely to be denied for “pre-existing conditions.” Unlike some states, California does not have “guaranteed issue” and in fact has had many cases of rescission, where patients are denied for coverage retroactively. For those who are denied, California has a small and underfunded high-risk pool that currently has a waiting list. In terms of benefits and other policies, California has stronger consumer protections compared to other states. * Senator McCain’s health care plan would expand the individual market, and more Californians would be at risk for being denied for “pre-existing conditions.” Senator McCain’s plan would ask patients who are denied to rely on the state’s “high-risk” pool, but the pool is inadequate for the existing population, much less a greatly expanded individual market. * Senator McCain’s plan would also strip away consumer protections by allowing insurers to sell across state lines, avoiding California ’s existing consumer protections. According to CAPAF, insurers could avoid over 40 benefit requirements and other state laws. These laws currently require insurance companies to cover benefits like breast cancer and cervical cancer screenings and to ensure other consumer protections, from fiscal solvency standards, to providing the opportunity for an independent medical review. California consumers who want a second opinion about the denial of a treatment might not be able to go to the California Department of Managed Health Care, as is their right now, but to the insurance commissioner of another state. * Senator Obama’s plan would institute additional insurance oversight and consumer protections, including “guaranteed issue,” and keep existing state protections, like independent medical review.
Again, the chart and reports are available at the Health Access California website, at: http://www.health-access.org
Health Care for America Now is a national grassroots campaign currently asking Members of Congress, “Which Side Are You On? – the side of quality, affordable health care for all or the side of leaving us alone to fend for ourselves in the bureaucratic, unregulated insurance market? HCAN’s Statement of Common Purpose includes 10 principles the campaign believes will lay the foundation for effective, comprehensive health care reform in 2009.
Health Access California (www.health-access.org) is the statewide health care consumer advocacy coalition, working for the goal of quality, affordable health care for all. Health Access California was the sponsor of the many HMO consumer protection bills passed in the past decade, including the creation of the Department of Managed Health Care and independent medical review. Health Access has also been actively involved in supporting numerous coverage expansion efforts, through bills and ballot measures. Health Access is a lead partner organization in California for the Health Care for America Now! campaign.
Health Care for America Now is made up of millions of individuals and more than 275 organizations nationwide. It’s steering committee includes ACORN, AFSCME, Americans United for Change, Campaign for America’s Future, Center for American Progress Action Fund, Center for Community Change, MoveOn.org, National Education Association, National Council of La Raza, National Women’s Law Center, Planned Parenthood, SEIU, UFCW, and USAction.
Health Care for America Now and Health Access California are both section 501(c)(4) issue advocacy organizations, HCAN and each of its members conducts and funds only activities appropriate to its tax and election law status. This statement was not funded or endorsed by HCAN’s 501(c)(3) members. ###
Several of the analyses of the Obama plan repeat the old canard that an obligation for employers to pay for health benefits for their employees, either by providing health coverage or by paying into a purchasing pool, are job killers. Joseph Antos, Gail Wilensky and Hanns Kuttner in a recent Health Affairs piece say, “Wages and employment would fall….The pay or play mandate, which is meant to help workers who do not have insurance gain coverage, could instead undermine their chances for economic success.” In a recent piece in the New England Journal of Medicine, Antos opines that the added cost of a pay-or-play mandate “would be covered by lowering wages or benefits or reducing employment.”
This is precisely the same argument that is made against the minimum wage in its various incarnations, including minimum wage increases and living wage ordinances. It is not true for the minimum wage. And it is not true for an employer obligation to pay for health benefits.
Moderate minimum wage increases are now widely recognized to have little or no effect on employment. Economists David Card and Alan Krueger who did the original studies on the impact of the minimum wage (and the further studies when many other economists tried to rip their research apart) found that the minimum wage increases had little or no impact on employment. Why? Low income workers spend what they make. And one of the places they spend that money is at fast food restaurants.
This should not be a surprise. It is why we have unemployment insurance: so when people are unemployed, they have some income so they can keep paying the rent and buying groceries. Unemployment insurance is one of the social insurance mechanisms that prevent recessions from turning into Great Depressions. That is why unemployment insurance was part of the original Social Security Act in 1935.
What about health care? The UC Berkeley Labor Center has done a series of pieces on the impact of employer mandates in various health reform proposals in California. A piece they did in July 2007 found modest positive economic impacts from both the health reform proposal by Governor Schwarzenegger and the competing measure, AB8 by then-Assembly Speaker Nunez and then-Senate President Pro Tem Perata. As economist Michael Reich observes in his foreword,
The authors find that the leading health reform proposals for California have been crafted in a manner that is not likely to generate adverse employment impacts. According to their findings, most firms will experience little or no net change in business operating costs after a short adjustment period. Consistent with the best research on the minimum wage, payroll and cost increases of these magnitudes are unlikely to reduce employment in California, while improving the health status of many Californians. Moreover, both health reform packages analyzed would boost productivity as workers take fewer sick days due to poor health and as workers are more able to work where they are most valuable, with their job mobility less hindered by health insurance concerns.
Just as with the minimum wage, thoughtfully designed employer obligations to pay for health benefits do not cost jobs—and in fact may have positive economic impacts.
We would postulate that the economic benefits go beyond those cited by Michael Reich. In the same way that unemployment insurance, Social Security and Medicare help to underpin economic security for millions of low and moderate income Americans and to contribute to the prosperity of the business community which depends so heavily on consumer spending, an obligation on employers to pay for health benefits may also help to contribute to economic prosperity. This is especially true when we look at low and moderate income working families, precisely those families whose wages have stagnated over the last decade.
Again, it is low and moderate income Californians (and Americans) who are mostly likely to face high health care costs, because they are more likely to be uninsured or underinsured---and providing affordable health benefits will increase their disposable income, helping to revitalize the economy. This is not fanciful: we report here on study after study showing that low and moderate income people suffer most from medical bills and medical debt problems. A recent study by the Commonwealth Fund found that more than half of all low and moderate income Americans (defined as incomes under $40,000 annually) had problems with medical bills or medical debt.
And it is low and moderate income workers that lack power in the labor market, as demonstrated both by the lower compensation they command and wage stagnation over the last decade. (Lower wages usually accompany less generous benefits: this is not perfectly so but generally true.) Providing these lower income workers affordable health benefits and minimizing problems with medical bills and medical debt so that they have adequate access to care, means they would have more money to spend on other things. And live healthier and longer.
Is there a benefit to our economy from providing affordable health benefits to low and moderate income working families? Do reform proposals, like that by Obama or those we supported in California, have an economic impact similar to unemployment insurance, Social Security and Medicare, the social insurance programs which help to underpin our economy? Particularly when we look at lower income working families, we ask whether adequate, affordable health benefits would help them to have a foundation of income security, the kind of income security that helped to power the American economy for so many decades and that today is lacking for so many.
After this week, it's clear that health care is a presidential-level issue. We have everything from television attack ads to key Paul Krugman op-eds on the health proposals. It got lots of conversation in the presidential debate tonight.
In answered to Tom Brokaw's question, I would say that health care should be a right (as Obama answered, and his plan moves in that direction), and a responsibility (as McCain an answered, but whose plan shifts responsbility to the individual, rather than employers and others). Unfortunately, right now, to use other terms from the debate, health care is currently a privilege enjoyed by a shrinking majority, and a commodity that is costing us dearly.
Merrill Goozner at GoozNews asks if this is the first time a presidential candidate fully embraced the notion of health care as a right for every American. Regardless, it's certainly progress.
Obama just killed McCain on the health care question in the presidential debate and shows his mastery of the issue over McCain.
Obama explained why we can't go across state lines -- because insurers could shop around for a juridiction that did not guarantee cancer screenings or other basic health care.
Obama explained why government needs to get involved to go after insurers whose abusive business models leave people with hundreds of thousands in medical debt, and begging for treatment on their deathbeds.
And most importantly, Obama insisted that health care was a right -- not, as McCain said, a responsibility.
I missed this story yesterday, but the Wall Street Journal reported that we've got it all wrong -- McCain's plan wouldn't tax the health care benefits we get from our jobs. Wouldn't think about it! And in fact, Obama is lying about it!
(By the way: McCain didn't seem to contest the idea that he was taxing employer-sponsored coverage when it was brought up by others, such as the Commonwealth Fund in their January 2008 analysis, this story in the New York Times from May 2008, or this description of his plan from his own website from February 2008, (which I handily printed out at the time, made into a pdf and highlighted for relevant comparisons). I noticed on his current website, he actually uses slightly different phraseology so he doesn't mention the 'bias toward employer-sponsored health insurance' that he previously references.)
Here's a quick summary:
McCain's health care plan is based on the idea that individuals should have more "choices" when choosing their health insurance, so he gives everyone a $2,500 tax credit ($5,000 for families). That way, people can "choose'' which plans work best, thus "fostering competition and innovation.'' But analyses have revealed that the tax credits would cost $3.6 billion, after he claimed it wouldn't cost the government anything at all (leading many to surmise that the money came from the tax he would impose on employer-sponsored coverage). Forward to this past week, when Obama has begun hitting hard with ads like this against McCain's health plan, and that makes him really mad. So that's what leads to his policy director saying McCain would not tax the middle class. Instead -- McCain's campaign says it wants to target and reduce Medicare (and the 41 million seniors on it) and Medicaid (with its 60 million enrollees).
Is that supposed to make it better?
So basically, rather than tax middle-class Americans -- we're weakening the system that the parents of working middle class Americans rely on? On top of that, we're weakening the safety net that millions of children, disabled, seniors also rely on.
I just finished watching Obama's half-hour speech on health care delivered this past weekend in Virginia. (I've tried to embed, but if that doesn't work, here's the link: http://www.youtube.com/watch?v=g9PIN03qGjg)
What struck me about his speech is two things about how he framed the McCain plan. First, there's the anticipated connection to higher income taxes -- because McCain's plan would essentially tax as income the amount employers pay for your health care.
But beyond that, Obama also links to that the notion that it'll be harder to keep the insurance that you have already. The idea that people would lose what they have scares the bejeezus out of them. But it's true. McCain's plan would be a disincentive for employers and some employees to take up employer-sponsored healthcare. The result is as many as 20 million Americans who currently have insurance would lose it.
For the record, Obama's plan does NOT mandate health coverage, as Gov. Palin suggested last night. That was the big "difference'' between his plan and the Clinton plan.
Also, McCain's plan would leave an additional 20 million uninsured, not 5 million as Gwen Ifill had suggested. Biden later corrected this point. It's significant because -- in context -- it would result in a 150% increase in the uninsured.
That's allI can remember, at this very moment, that annoyed me (on health care specifically)....I guess ....other than the fact that Palin didn't answer the question about why the McCain health care plan would increase taxes on the middle class.
Ezra Klein at The American Prospect said "Joe Biden just offered the most lucid and concise demolition of McCain's health care plan that I've heard. He hit the taxation of employer benefits, the fact that 20 million would lose their health coverage, the failures of the individual market, and all the rest. It was [beautifully] put."
Marie Cocco at the Washington Post, perhaps watching a different debate than Ezra, said that "Biden countered with a convoluted explanation of how that $5,000 wouldn’t be enough to purchase what is now a policy costing about $12,000, and which is subsidized with tax breaks for employers. That’s about as far as it went, and it’s not nearly far enough. "
Cocco continued,"In fact, McCain’s health insurance proposal would eliminate tax benefits employers now get for offering health insurance to their workers. This would effectively end the work-based health insurance system. Families would be left to purchase policies on their own, those who are sick would face much higher premiums, and the number of uninsured would rise, rather than fall, according to independent analyses."
Merrill Goozner at GoozNews goes deeper into the substance of the debate, trying to take seriously aspects of the McCain plan--perhaps more seriously than McCain seems to take them.
Some make a case that the tax deduction for employer-based benefits can be better structured to be more efficient and equitable. But in the current system, removing this tax benefit would be a takeaway for both employers and employees, and give a significant push for at least some employers to drop coverage of their workers.
What workers would get in return is nothing close: a tax break that may or may not be of a similar dollar amount, but almost certainly not of the same value. For those workers swtiched from the employer-based coverage to the individual market, they not only lose the employer contribution, but the efficiency and bargaining power of group purchasing. Even with the same dollar amount in tax benefit, whatever they buy in the individual market will be a much more scaled back, less valuable plan, on average.
And for some with "pre-existing conditions," they lose the ability to get insurance in the first place. McCain's policy people said he would boost state high-risk pools, like California's MRMIP. As we said with the recent veto of AB2 here in California, such efforts are deserving but too small and inadequate as a fix for the problem... and by shifting the tax burden to shift people out of group coverage in the individual market, the plan actually makes the problem worse.
It's not just a tax increase, as the commentators indicate... It's a tax increase that leads to a further unravelling of our health system.
The Commonwealth Fund today released a report showing that Obama's health care plan would help more uninsured. Way more. Like 17 TIMES more uninsured covered at the end of 10 years. (34 million versus 2 million)
I think my favorite part is this chart explaining the key differences between the plans. "Aims to cover everyone: Obama -- Goal; McCain -- Not a Goal."
This is John McCain on taxpayer-funded health care
Wednesday, October 01, 2008
Sen. John McCain met with the Des Moines Register's editorial board this week and had this to say about health care. A Register editorial board writer asked whether he had always been covered, in his adult life, by taxpayer-funded health coverage, whether as a veteran, Congressman or senior over 65.
"You know that's an interesting statement, isn't it? Um, so, and I have never been an astronaut, but I think I know the challenges of space. And I have never done a lot of things in my life that I think I am familiar with. I've always been a free enterprise person who thinks that families make the best choices for themselves and their future. That's a dramatically different philosophy than my Democrat friends, in my view. who think that government is the answer. Sen. Obama wants to create a huge health care bureaucracy for America. We've seen that movie before. So the answer is that most of my life, in serving my country I have had health care. I did go a period of time where the health care wasn't very good."
I take particular umbrage to this part: "I've always been a free enterprise person who thinks that families make the best choices for themselves and their future."
McCain's health care plan would provide refundable tax credits for individuals or families to buy insurance, but also count as income what a family's employer pays for their insurance. Taxing what employers pay for health insurance would actively discourage health insurance through work.
Job-based insurance is an important part of our current system, extending coverage to 61% of Americans. Job-based coverage allows workers to join an insurance pool, which is their employer. Employers can leverage lower rates, unlike a person out on their own in the insurance market.
In the individual insurance market -- which is where Americans will be forced to hunt for coverage if their employer shirks that duty -- consumers choices will be:
expensive comprehensive coverage
slightly less expensive coverage that leaves my family exposed should anything happen
nothing at all.
That's not a real choice. Especially in the world of insurance where anything goes -- where not everyone can be assured that they'd be able to get coverage, somehow, or that the coverage is actually meaningful (like covering doctors visits, prescription drugs, hospital visits, cancer screenings -- basic health care.)
Hasn't this economic meltdown taught him anything?
Right now, the hot magazine is not Rolling Stone, or Wired, or Maxim, or People, or but Contingencies, the publication of the American Academy of Actuaries.
Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.
McCain wants to eviscerate consumer protections--including fiscal solvency standards--for health insurers, which seems only to invite the disaster we now see on Wall Street. As Beth indicates, there's lots of history to suggest what the problems would be with such lack of oversight.
We need more, not less, oversight over the banking, financial, and insurance industry. $700 billion is just the latest figure of what the price of such lack of oversight is.
We have already commented on the bail-out of AIG this week and what it says about our values.
It also says something important about the value of regulation. Apparently AIG’s problems were in its “bond wrap business” which some regard as an insurance product, others as a financial product--and we wonder whether it was something designed to escape normal regulatory scrutiny.
What the AIG failure and the failure of several major financial firms remind us is that financial solvency requirements, including adequate capital, are basic consumer protections. Think about George Bailey in It’s a Good Life. Think about a run on the bank, something most of us have only seen in Mary Poppins but that caused the failure of thousands of banks in the Depression. Financial solvency is a basic consumer protection: it says that your money, your insurance will be there when you need it.
What does this have to do with health care? Well, apparently it is another one of the things that John McCain forgot when he proposed his health plan. Or overlooked.
Financial solvency of health insurers is regulated state by state. Capital requirements for health insurers and plans vary by state.
California is no angel when it comes to financial solvency and health insurance. Let me recount a bit of history.
The Knox-Keene Act (authored by two legislators named Jack Knox and Barry Keene, both good guys who did lots of good work) was enacted in 1975 because some HMOs were taking capitation payments from employers and individuals and sending them to the Bahamas. Literally. So all that language about adequate networks and timely access to care was devised to assure that the HMOs actually HAD contracts with doctors, hospitals and other needed services. And equally important Knox-Keene set real and enforceable standards for tangible net equity and other measures of financial solvency so that HMOs had enough money on hand to pay the doctors, hospitals and other providers. Gee, whiz, pretty basic.
Well, not basic enough. In the mid-1990’s, some managed care plans “delegated” responsibility for managing care to medical groups. These medical groups were not five doctors down on the corner: these medical groups included hundreds or thousands of doctors and took responsibility for the care of tens of thousands or even hundreds of thousands of consumers. In some cases it was just care provided by physicians but in other cases it included hospital care as well as care now provided on an outpatient basis, like chemotherapy and most surgery. And guess what had happened by the late 1990’s? Yup, many of the medical groups were not adequately capitalized and lacked basic financial management so they were going upside down left and right. So part of HMO reform was new regulation of the financial solvency of medical groups. The very first act of Daniel Zingale as the HMO czar was to require all medical groups to have financials audits. Shockingly, some medical groups responsible for the care of literally tens of thousands of Californians lacked something so basic as financial audits. Zingale who had run various non-profits was as shocked as we were that medical groups handling millions of dollars lacked routine financial audits.
And in between 1975 and 1999, California joined many other states in having similar experiences with MEWAs. What is a MEWA? A multiple employer welfare arrangement created by non-union employers that cannot participate in labor-management trusts. Milo Kaufman, now Insurance Commissioner in Maine, wrote a 2004 paper for the Commonwealth Fund titled “MEWAs: The Threat of Plan Insolvency and Other Concerns” that highlights the lack of financial solvency as one of the basic problems with MEWAs. California fixed its problem by grandparenting in a handful of financially solvent MEWAs and closing the barn door. The classic MEWA Ponzi scheme involves an entrepreneur of some sort cobbling together a bunch of employers by promising them big discounts on health coverage, then failing to collect enough premiums to meet claims when they come in. Who loses? Well, everybody but the entrepreneur. Sound familiar? Sound just like Wall Street in the past few months?
There is a long history of various schemes in which insurers or entities standing in the place of insurers attempt to lower premiums by failing to collect enough to pay claims. While those of us who worry about insurance may argue about what constitutes an adequate reserve, everyone who understands insurance agrees that adequate reserves are basic to insurance.
So what does all this have to do with John McCain? Well, his plan allows “people to buy health insurance nationwide instead of limiting them to in-state companies”. Most of the discussion has focused on the consumer protections that consumers have won---whether it is mental health parity (47 states), reconstructive surgery after breast cancer (49 states), mammograms (50 states), maternity stays (50 states), well child care (31 states) or coverage of newborns and adopted children. (If you are thinking, good grief, people had to get legislation to cover stuff this basic! Then you know why we fought so hard for HMO reform.) (Source: Council for Affordable Health Insurance: www.CAHI.org)
All those consumer protections are important. But making sure that insurers are financially solvent is a basic consumer protection as well. And just as states vary in the consumer protections they provide, they vary in the financial solvency requirements they impose on insurers.
John McCain has now decided that perhaps a bit more regulation would have been in order to prevent the debacle on Wall Street. But the premise of the McCain health plan is that deregulation will solve the problems of health insurance. Really? Or will we just end up with another debacle like the one we are witnessing in the financial markets?
If there's one thing you read about the presidential election related to all the happenings on Wall Street, take a look at Ron Brownstein in the National Journal. It makes the link between the financial sector crisis and policy on retirement, health care, and other hot-button issues. He quotes Jacob Hacker, author of the The Great Risk Shift, and soon-to-be-professor at UC-Berkeley, about the fundamental question in this election. Read the whole thing, but's here's a few paragraphs:
Although neither McCain nor Obama has framed the situation this way, their reactions to this transfer of risk and responsibility represent a fundamental dividing line between them. Like President Bush, who touted an "ownership society," McCain has welcomed these shifts of responsibility as giving individuals more control over their financial future. On several fronts, McCain in fact wants to accelerate these trends.
Today, most Americans still receive their health insurance through group coverage (either from government or employers) that shares risk and cost between the healthy and the sick. Relatively few obtain insurance in the individual market, which exposes consumers to much wider variations in cost and coverage depending on their health. McCain's proposal would push more people toward the individual market (perhaps 20 million more, according to an independent study released this week) by replacing the tax break that promotes employer-based coverage with an individual tax credit....
Obama, by contrast, wants to strengthen the institutions that promote the sharing of risk. His health care plan aims to buttress group-based coverage, either through employers or new government-sponsored purchasing networks. He adamantly opposes private accounts under Social Security and would instead offer tax incentives for workers to invest for retirement in accounts intended to supplement Social Security's guaranteed benefits.
In all these respects, the McCain-Obama contest represents a fork in the road that will likely determine whether the nation continues to shift more financial responsibility to individuals, or seeks opportunities to restore more sharing of risk. This week's chaos on Wall Street, which rattled millions of workers relying on the markets to fund a decent retirement, shows how much average Americans have at stake in that choice. "This is a critical watershed moment," Hacker correctly notes, "because it really captures in sharp relief both the stakes and what the core of this debate is."
Brownstein overlooks that Obama did explicitly counter the "you're on your own" philosophy of the so-called "ownership society" in his convention speech, which didn't get much attention because of the announcement of Sarah Palin's selection the next day.
In Washington, they call this the Ownership Society, but what it really means is - you're on your own. Out of work? Tough luck. No health care? The market will fix it. Born into poverty? Pull yourself up by your own bootstraps - even if you don't have boots. You're on your own.
But the rest of the analysis by Brownstein and Hacker is spot-on. This debate is bigger than all of us, including Obama and McCain.
Lots in the news about the Presidential candidates respective health plans today.
Health Affairs has just published an analysis of Obama's and McCain's health plans. Ezra Klein has done his own summary of the Health Affairs' take on the Obama and McCain plans. Bob Herbert of the New York Times talks about McCain's awful health agenda. Wall Street Journal (!) also has an op ed on why Obama's plan is better.
McCain's plan, according to health policy academics, would result in more than 20 million people losing their work-sponsored health coverage -- leaving them to fend for themselves in the individual insurance market. I'm not sure how this improves anyone's lot -- especially in a state like California, where it would be an exagerration to say the individual market was regulated.
Meanwhile, the critiquers of the Obama plan (which includes an adviser to the McCain campaign), opine that it amounts to more regulation (because deregulation works sooooo well) and more spending (duh, it's expensive to pay for health care.)
In this Wall Street Journal story from yesterday, Wellpoint's CEO is appallingly frank:
In calls with analysts and investors, WellPoint executives have stressed that it is working to keep its more-profitable business and that the customers leaving tend to be costlier ones. "We're keeping good members and healthy lives that we had been concerned about [losing] in the past," Ms. Braly told analysts last month.
Translation: "Awesome. We won't have to spend money paying for sick people.'' (This is how Sarah Palin thinks the market should work?)
The story, however, touches on a familiar trend throughout the insurance industry -- the loss of employer-sponsored plans. Since 2001, the percentage of firms offering coverage has slipped nearly 10% in less than a decade to 59%.
Nevertheless, Wellpoint increased premiums yesterday to placate investors and as a result expects about 150,000 more business members (on top of the 189,000 business members they've already lost this year) to drop coverage.
Sidenote: Of course, we can expect the number of employers that would drop coverage to *increase* if McCain/Palin win office, as their plan allows insurers to run amok and tax businesses for providing this basic benefit to workers, making the individual market (least efficient, most expensive) more attractive.
The Wall Street Journal today contains an analysis of Rep. Veep candidate Sarah Palin's policy record. Here are the relevant health portions:
Gov. Palin didn't make health care one of her top priorities, but where she did take a strong stand on health, it was for the free market.
"Health care must be market- and business-driven, rather than restricted by government," her office said in a January statement.
Her overall approach is much like Sen. McCain's -- loosen government regulations to allow for greater competition, along with more information for patients to make good choices.
Addressing the uninsured was less of an issue for Gov. Palin, much as it is less significant for Sen. McCain. She was reluctant to support a significant expansion of the state's version of the Children's Health Insurance Program, called Denali KidCare. She signed a bill that raised eligibility to allow families with incomes up to 175% of the poverty level -- stingy compared with other states.
Great. So she doesn't *really* think addressing the uninsured is an issue. Yet, Alaska, according to the latest Census Report, her state (and it's teeny tiny population of 664,000) has nearly the same proportion of uninsured as California -- 17.3 percent (to our 18.6 percent). The number of uninsured in her state could populate the entire town of Costa Mesa -- home to South Coast Plaza and 113,955 Orange Countians. (AK's uninsured is 115,000).
Just saw a video broadcast at Mile High Stadium before Al Gore and Barack Obama's speeches. It was about an Obama supporter whose mother had cancer, and her experiences with a health system that needs to be reformed.
"It was horrible. It was one of the worst experiences to go through. I saw the medical system firsthand, and it was horrible.... Towards the end, she had gotten stable, and was stable enough for transfered, to be removed from the ICU. When I was trying to get a doctor to admit her to another hospital, the doctors couldn't admit her because they didn't have the proper insurance. She had Medi-Cal. These doctors didn't accept Medi-Cal...."
Alas, she's a Californian, and at least this part of her story shines a national spotlight on the process of access for the 6.8 million Californians with Medi-Cal coverage.
Yet at the same time, the budget crisis threatens to cuts further into Medi-Cal, including the already lowest-in-the-nation provider rates that lead more than half of the state's doctors not to take Medi-Cal patients.
California still has the highest number – not percentage – of uninsured residents at 6.7 million, compared with 5.7 million Texans. The Texas number is up from 5.5 million in 2006.
But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)
"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.
"So, there you have it. Voila! Problem solved."
Amazing...a McCain advisor wanting to simply define away the uninsured... in a just world, that should get a public rebuke worse than Sen. Gramm suggesting that America was only going through a "mental recession."
Some commentators have already pounced, including Ezra Klein and Joe Klein (no relation).
But even these rebukes don't actually explicitly refute the misconception that Goodman's comments are based on--so I will. Yes, Health Access California was founded 20-years ago, from a coalition working for a law that people are not turned away from emergency rooms based on insurance status. The eventually-passed federal version of that law, EMTALA, is important, but let's be clear what it does, and doesn't do:
* The law only requires emergency rooms to stabilize patients, not treat them. If you just had a car crash or heart attack, they will treat you, but if have cancer, asthma, diabetes, or any other long-term illness, there's no obligation by the hospital.
* Even in an emergency situation, there's no prohibition on what the hospital can charge. And in fact, the uninsured is often charged 2-4 times what insurance companies and public programs pay for the exact same service. That's the bill they get.
So even our EMTALA law does not ensure access to care, and certainly not *coverage* for care. People need care, and they need coverage to pay the bills. And the Census figures show a staggering number of people who have neither.
The irony is that the Census figures do have a "voila" moment. It shows that policy matters: states like Hawaii, Massachusetts, and Minnesota--that have set standards for employer based coverage, or have expanded public programs--have significantly lower uninsured rates in comparison to other states.
We know what we need to do to say "Problem solved!" But it's not by sweeping it under the rug.
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.
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.
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.
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.
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.
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.
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.
* 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The Lewin Group, the most respected health economists, have rated the dreamy Jacob Hacker's Health Care for America plan -- which has served as the basis for Democratic Presidential candidates Hilary Clinton, Barack Obama and John Edwards' health reform proposals.
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.
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...
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 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.
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.
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 further regulating insurers, they argue that less regulation would allow insurers to offer cheaper plans with scaled-back benefits.
The chart does not really help illuminate these important distinctions--ones that will have a direct impact on people's lives.
In the national debate about mandates, many are making mountains out of molehills.
To recap from earlierposts on this blog: Even though their plans are incredibly similar, Clinton and Edwards are making a big deal that Obama's plan doesn't include one element, an individual mandate, even though he has said repeatedly that he would consider including an individual mandate later.
Obama says he wants universal coverage and would accept a mandate, but first wants to focus on making coverage available and affordable. Clinton and Edwards say they will make coverage available and affordable (through largely the same mechanisms), and then place a mandate to ensure everyone is in the system.
I am in agreement with Robert Laszewski at the Health Policy and Marketplace Review, in his analysis when he says: "So, when the day is done, I don't see much real difference here."
Some, fairly progressive health policy folks, including those who support single-payer, criticize Obama for not including a mandate. This includes Jonathan Cohn at The New Republic, and Maggie Mahar of HealthBeat, in perhaps the best of the recent articles, who quotes Princeton professor Paul Starr.
“The secret power of the mandate is that it is as much a mandate on government as it is on individuals. It is a mandate on government to make coverage available and affordable. For it would be patently unacceptable to demand that people have coverage and then provide no practical way for many people to get it.”
Having the mandate as a challenge to policymakers to make coverage available and affordable is a good thing--unless the policymakers don't meet the challenge. Governor Schwarzenegger clearly came to the health reform conversation out of a belief in an individual mandate, and as a result he did some--but not all--of the things that a mandate would require. For example, his original plan only had subsidies that were limited to folks up to 250% of the federal poverty level.
Leave it to Ron Brownstein of the National Journal (formerly of the LA Times) to cut through some of the clutter. He appropriately finds the geneology of the individual mandate and recognizes the critique from both sides of the aisle (including yours truly), but he also identifies that the issue is not ideological, but practical:
Although Republicans raise mostly ideological objections to an individual mandate, Democrats express more-concrete concerns. For liberals, notes Anthony Wright, a California health care advocate, the key issue is whether the government subsidies are sufficient to ensure that uninsured families can afford the coverage that a mandate compels them to buy...
It is on this front that Hillary Clinton faces the toughest questions today. She responds to concerns about the mandate's affordability by noting that her plan (like Edwards's) would cap the share of income that individuals must contribute to premiums, with government subsidies covering the rest. But, wary of providing a target for opponents, her campaign won't say what that cap will be. Although Clinton has promised generous funding for the public subsidies, it's difficult to see how uninsured families can judge her proposal without knowing even roughly how much of their income it would require them to contribute to buying insurance.
The mandate muddle masks the real question: how much actual help does the health plan provide people?
I would much rather that the candidates were competing on the level of subsidies they were providing low- and middle-income Americans, on how much they were going to use group purchasing power to bargain down the cost of coverage and drugs, etc. That's what we should use to rate one proposal superior to another. That's how any California health reform plan should be evaluated.
People want coverage: the question is what does any plan do to help them get the coverage they want and need--and whether that is sufficient for specific populations.
In the discussion over the individual mandate among the presidental candidates, bloggerEzraKlein, NY Times columnist Paul Krugman, and others with good liberal credentials are making the progressive case for an individual mandate, and even making it a litmus test for a serious health proposal.
ARE INDIVIDUAL MANDATES A MUST? The argument goes like this: progressives believe in social insurance, where everybody needs to participate. If there isn't a requirement that we all need to contribute to health care, you undermine the fabric of social solidarity, the concept of universality. There's something to that.
All of these commentators seem to indicate that the Clinton (or Edwards) plans, with an individual mandate, would be far better than the status quo. In the context of a good proposal, they don't make individual mandates something to attack; but they don't believe the individual mandate is the essential dividing point between Clinton and Obama, or between a workable or progressive proposal and one that is not.
FRAMING THE QUESTION: Some have seen the individual mandate not as a liberal but as a conservative construct, and not just because of it origins with moderate Republicans like Senator Chafee in the early 1990s, and Governors Romney and Schwarzenegger more recently. Under this belief, the individual mandate enforces a more conservative point of view, that of personal responsibility.
As Health Access put forward in our critique of an individual mandate from 2006, an individual mandate implies that the issue is that people need to be required to take up coverage, rather than acknowledging and addressing the real barriers that exist for people to get they coverage they actually want. The Health Access paper was responding to previous legislative proposals, including those by former Assemblyman Keith Richman (R), which did not propose to do much to address those barriers.
This year, Governor Schwarzenegger took the implications of the individual mandate seriously, meaning putting in place significant subsidies, a minimum employer contribution, and insurance market reforms so that people had a chance to meet the mandate. And there is where the common ground has been, on providing people the help they need to get the coverage they want. Our critique has been that the Governor's plan did not provide sufficient help to many low- and moderate-income populations facing the mandate--and that's what the negotiations continue to focus on as we speak.
MAKING THE MANDATE MOOT: At the same time, Health Access, in that very same critique and elsewhere, was clear about the fact that we don't oppose the notion of individual responsibility, whether it's a payroll tax to finance a single-payer system, or a worker requirement to take-up coverage offered by an employer, as long as it is deemed affordable.
The Democratic presidential plans--by Clinton, Edwards, and Obama, with and without an individual mandate--are in that vein: they largely rely on expanding group coverage, through public programs, employers, or purchasing pools. To the extent that it exists, the individual mandate is incidental, to bring in people and automatically enroll them. Obama actually doesn't even argue against an individual mandate--he says he would consider it, but only after his plan has provided available, affordable coverage. It seems Clinton and Edwards are there as well, providing assurances to people that coverage won't be more than a certain percentage of their income.
So is an individual mandate a liberal or conservative idea? Does it matter? People want health coverage--to get the care they need, and to protect them against financial risk. If coverage is available, affordable, and automatic, then the question is moot.
The real issue is what are the policies in place to provide for coverage that is available and affordable for all Americans. That's what I hope the candidates spend more time debating.
The Los Angeles Times reports on the debate among the Democratic presidential candidates over the so-called individual mandate. It been strange seeing this play out nationally, within the very vague terms of presidential campaign position papers… while we’ve been grappling with the nuts-and-bolts of these same issues here in Sacramento.
I'm a little confused about the fuss. The three proposals, by Edwards, Obama, and Clinton, are all very similar. Edwards and Clinton are trying to make a distinction with Obama, in that they have a individual mandate, and Obama doesn't. But Obama does not say he oppose the individual mandate--he said repeatedly that he would consider it, but his first goal is to make coverage affordable.
At the same time, Clinton and Edwards both propose to do similar things as Obama to make coverage affordable, providing certain assurances and subsidies (such as saying that premiums won’t be above a certain level of income.) So there's not much difference in terms of the help actually offered to voters: all would significantly expand public programs, bolster employer-based coverage, and offer new public insurance options for folks.
When Clinton attacks Obama for not being universal, Obama responds that their proposals aren't either, unless they are proposing onerous enforcement. All three of them rely on automatic enrollment mechanisms, especially at work, to get folks covered. All of them get pretty close to universal.
So why they are making such a deal about a relatively small items. And if they are going to spotlight their health care plans, why are they having an argument about the burdens, rather than the significant benefits, of health care reform?
The former mayor of my hometown, Rudy Guiliani, is downright scary in his pronouncements on health policy issues. And my suspicion is that he knows better, which makes me think even less of him.
Sara Mosle at Slate compares the lessons he learned from his prostate cancer experience now, and what he said and did at the time.
With all that's going on in California, we haven't covered the presidential candidates and their health care plans too much.
It has been covered by several blogs, including two by independent-minded folks who used to work in the insurance field.
This week, Joe Paduda in Managed Care Matters is at the annual progressive gathering of Campaign for America's Future, Take Back America. He's providing up-to-the-minute reporting of what the candidates are saying about their health plans. So far he's written on Obama, Edwards, and Richardson.
An article in the Wall Street Journal today titillates us with talk of a "rift'' between Republicans in Congress and the Bush Administration over money for children's health insurance.
Republicans and Republican candidates are representing states that have acknowledged that more needs to be done to cover middle income children. These states are applying for waivers that will allow them to include more children beyond the ceiling set by the federal governmnet at 200% of poverty level -- $34,340 for a family of three. (California is one of those Republican-led states that is seeking to expand its children's coverage program).
But none (except former Arkansas Gov. Mike Huckabee) is taking the President's meager allotment for the program to task. They're not even really inquiring about it.
The president has proposed to fund the State Children's Health Insurance Program at a piddling $5 billion over the next five years, which would leave many states -- including California -- woefully short of the amount they need. Advocates believe the amount should be an additional $65 billion over the next five years. Democrats are fighting for another $50 billion.
If health care reform is going to happen, funding children's coverage a cornerstone to that plan. All elected leaders -- Democrats and Republicans alike -- need to be pressuring the administration to increase those costs.
That will definitely involve more direct confrontation than what is going on now.
The New York Times yesterday reported that the Bush administration said it would "strenuously resist" plans to expand the State Children's Health Insurance Program, which funds California's Healthy Families.
They annoyingly "expressed concern about a sharp increase in the proportion of children covered by public programs in the last decade.''
WWWWeeellllll......
If businesses wouldn't keep dropping family coverage or making it harder for workers to cover their families, then maybe fewer children would need to be enrolled in public programs.
During the economic downturn, from 2000 to 2002, the number of businesses covering children dropped by 2.5 percent. In the same period, state and federal government saw a 2.9 percent increase in children enrolling in public programs. In spite of this administration -- and their friends in the business community, these programs have continued to grow.
Now, Bush is unwisely trying to restrict growth in these programs by reauthorizing the bare minimum ($30 billion over five years) for SCHIP, and making fewer children eligible. Meanwhile he's doing nothing to encourage more coverage on the other end.
Advocates, on the other hand, say we need about $85 billion over the next five years to do a good job. Surely, we can find $17 billion A YEAR for children's coverage if we've been able to find $413 billion for war the past five years. According to this fun calculator, we could have covered about 250 million kids by now.
It'll be interesting to see where the presidential candidates fall on this as we debate the issue over the next few months.
Not the automakers -- but the three frontrunners for the Democratic nomination for president in 2008 -- gave their take on health care reform for the next presidential term(s).
With the exception of Sen. John Edwards, who released his plan in February, none really had a solid plan, but echoed common principles. (The other two I refer to are Barack Obama and Hillary Clinton).
All tapped into the notion of shared responsibility and building on the existing system of employer-based coverage, while also trying to expand government-purchased health care as a stepping stone to a Medicare-for-all like system in the future.
It's pretty encouraging when everyone's talking about the same thing.
It was noted that Republicans were invited to talk about health care by the Center of American Progress, University of Nevada and Las Vegas, and Service Employees International Union, but none responded.
with a background as a consumer advocate and community organizer on many issues, including health issues for the last ten years in California and New Jersey.
