2008 To Be A Busy Health Care Reform Year in California

With the demise of comprehensive health care reform and the arrival of a horrendous budget deficit, California lawmakers are busy looking for ways to fix what they perceive to be the state’s broken health care system on the cheap. After all, the concerns are still there: too many uninsured, ever increasing health care costs, bad behavior by carriers. And lawmakers can’t spend all their time haggling over budget cuts. So health care reform will be an important part of this legislative session. The issue will no longer be front and center, but it’s still on stage.

Several health care reform bills were passed before the legislative deadline. They focus on specific aspects of health care. Indeed, several are repackaged nuggets from Governor Arnold Schwarzenegger’s and Assembly Speaker Fabian Nunez’s comprehensive health care reform package, Assembly Bill x1-1.

One issue the legislature will no doubt act upon this year deal with how carriers cancel the coverage of customers who failed to honestly or completely complete their original applications. Because these rescissions are retroactive to the original date of coverage, the customer and health providers are often left with substantial financial exposure. This is an area that cries out for legislative attention. Carriers have been fined millions of dollars for the practice by state regulators. Consumers are terrified that the coverage they’ve been paying for won’t be there when they need it most. Everyone realizes there needs to be a balance between protecting those who make innocent errors in their applications without rewarding those who purposefully game the system. If there is to be an imbalance, however, most lawmakers understandably would rather err on the side of protecting their constituents rather than insurance company profits.

AB 1945, by Assemblyman Hector De La Torre, would require state regulators to sign off on such rescissions before they take effect. AB 1150 by Assemblyman Ted Lieu aims to prevent carriers from setting targets for cancelling policies or awarding bonuses to their employees based on the number of policies they rescind. It’s unclear whether state regulators want or can handle the responsibilities imposed on them by AB 1945. The bill may simply be impractical. AB 1150, on the other hand, is likely to pass without much controversy.

One of the key features of ABX1-1 was its requirement that carriers spend 85 percent of the premiums they receive on medical care. According to the San Jose Mercury News, this Medical Loss Ratio requirement is reappearing in legislation sponsored by Senate Health Committee Chair Shiela Kuehl. I haven’t been able to find the legislative language advocated by Senator Kuehl. The compromise approach contained in ABX1-1 was widely supported, including by many carriers. It’s unclear whether the new legislation will simply accept that language, in which case it is highly likely to pass, or veer off into new, more controversial directions.

Senate President Pro Tem To-Be Darrell Steinberg is pushing another element of ABX1-1. His bill, SB 1522, would require the Department of Managed Health Care and Department of Insurance to establish five categories of individual plans. Carriers participating in that market would be required to offer at least one health plan in each of those categories. As currently drafted, it appears insurers could offer additional plans, too. This flexibility would preserve consumer choice and allow carriers to continue to innovate new plan designs. If, however, this flexibility is diminished, the results could be harsh for California consumers. 

These are just some of the bills introduced prior to the legislature’s submission deadline. Keep in mind, however, that any bill can be amended in virtually any way, so the filing deadline doesn’t have a lot of teeth. The number of bills seeking to reform the health care system is likely to increase before the weeding out process begins. This could be a good thing. It would be nice to see, for example, more focus on controlling health care costs, which is the real root of problems in the health care system.

In any event, 2008 is going to be a busy year for health care reform advocates. It won’t make as many headlines as 2007’s efforts, but that doesn’t mean this year won’t be even more significant than last year.

Congressional Health Care Reform Plan Waiting for New President

During their Ohio debate Tuesday night, Senator Hillary Clinton and Senator Barack Obama spent the opening 16 minutes diving deep into the minutia of their health care reform plans. The public has heard the debate many times before. One might be forgiven for believing the differences actually matter. They don’t.

The reality is that health care reform will be a top priority for either of these candidates should they gain the White House. What plan eventually emerges will be negotiated, compromised and updated so much and so often, it may bear little resemblance to the proposals Senators Clinton and Obama have put on the table. And that’s fine. No one has the secret formula. Crafting the best health care platform for America should involve a great many people not yet heard from.

Then there’s the health care reform proposal already waiting for the new president. Sponsored by Democratic Senator Ron Wyden and Republican Senator Bob Bennett, the Healthy Americans Act is the most bi-partisan and prominent bill stewing in the current Congress — or any recent one, for that matter.  Supported by a dozen senators, six from each party, in many ways it goes much further than the plans being promoted by the Democratic presidential candidates. And compared to Senator John McCain’s market-based reform plan, it’s downright radical.

Twelve percent of the Senate is a long way from a majority. But it’s a start. Even Senators Wyden and Bennett don’t agree with every aspect of their bill. The plan requires all Americans to buy coverage. It does away with the preferential tax treatment of employer-based coverage, forcing individuals to purchase their own coverage through regional purchasing pools. While it’s not a single-payer system, those pools do mean multiple governmental agencies will be running the show.

The Healthy Americans Act is, as it stands, seriously flawed. But that’s not the point. The details of this legislation don’t matter any more than the specifics of the candidate’s proposals. What matters is the existence of a bi-partisan coalition of Senators waiting for a president who is serious about building a consensus to appear on the scene. That’s fertile ground for a serious debate and equally serious negotiations about a complex and vital issue. And that’s good news.

Seeds of 1993 Health Care Plan Defeat Planted by Clinton

At the Democratic debate in Austin last week, Senator Hillary Clinton declared her experience in the 1990s in developing and promoting health care reform would serve her well if elected president. She claimed it would help her stand up to the special interests. Senator Barack Obama responded it was her approach to health care reform that doomed the effort. He is right. She is wrong.

Senator Clinton blames special interests, especially the insurance companies, for defeating the health care reform package she developed for her husband’s administration in 1993-94. There’s some merit to the claim. Tens of millions of dollars went to lobbying, advertising and organizing against the proposal. But while that level of spending would have made passage more difficult, if the plan had been well conceived and well promoted it would not have been enough. With Democrats in the White House and controlling Congress, the right plan, developed and sold in the right way should have been successful. And that was the problem. Under now-Senator Clinton’s leadership, the plan was developed in secrecy and presented to the public and decision makers with unforgivable ineptitude.

Senator Clinton talks a lot about reaching out to all points of view to fashion consensus policies and programs. Now. Then, however, it was her way or the highway. In late-1992 she began assembling a large group of very smart people to develop her health care reform package. They sequestered themselves in Washington and talked among themselves. Occasionally they’d seek input from outsiders. But like Ken Kesey’s Merry Pranksters, you were either on the bus or off the bus. And if you were off the bus, your opinions didn’t matter.

This created two problems. First, developing policy in an echo chamber rarely works. The results may look good when considered in a vacumn, but when exposed to the real world, one flaw cascades through the interwoven assumptions, reducing the whole to dust. The Clinton health care plan of 1993 and 1994 was beautiful to behold, an exquisite example of theoretical policy. It was also fragile. Because the Clinton administration was unwilling to accept advice or input or, heaven forbid, changes, from the outside, it lacked a foundation to withstand deep scrutiny. Much to the surprise of the Clinton health care working group, their plan was flawed. And those flaws led to the unravelling of the whole.

Second, excluding members of Congress from the process was just stupid. By ignoring even Democrats in Congress, there was no one at the other end of Pennsylvania Avenue who had any stake in the outcome. In fact, it merely engendered hostility. I participated in three Congressional hearings, representing the National Association of Health Underwriters (NAHU is an association for health insurance agents and other professionals). None of the questioning dived deeply into the Clinton health care plan. There was plenty of questions concerning other reform proposals, but our criticism of the Administration’s plan was pretty well accepted by the Congressional panels.

The lack of an open process is one of the reasons Assembly Bill X1-1 failed in the California legislature. To their credit, the staff of Governor Arnold Schwarzenegger consulted with far more “outsiders” than the Clinton health care task force. But these were seriel discussions held in private. No one really knew what the entire package looked like until months into the Year of Health Care Reform. As a result, when the legislation reached the State Senate, there were few there who had a stake in its passage. When faced with the state’s budget crisis, it was easier for them to let health care reform slide away.

The lesson is clear: developing health care reform requires an open, inclusive process. Every opinion and perspective needs to be represented. Senator Obama gets this. Unlike Senator John Edwards, who claimed he wouldn’t let the insurance industry participate in developing his health care reform legislation, Senator Obama said they’d have a seat at the table, they just wouldn’t be able to buy them all.

It’s this approach to openness and collaboration that holds the greatest promise of success. Senator Clinton tried the old way. It didn’t work. Her continuing the blame the special interests instead of her own mistakes for the defeat of the Clinton Administration’s health care plan shows she may not have learned the right lesson. And that’s another reason she’s no longer the frontrunner for the Democratic nomination.

The Wal-Marting of Health Technology

A few years ago WellPoint, then the nation’s second largest commercial health care plan, offered to give thousands of doctors in its network either a free Dell computer system or a free PDA customized to help with prescriptions. The idea was to speed the adoption of simple technologies by the medical community. The computers would physicians automate more of their office functions. The PDA would help them more quickly, easily and safely prescribe medicines. And it was free. It was also a failure.It turned out, as then WellPoint chairman Leonard Schaeffer once put it, “Free wasn’t free enough.” Integrating technology into their practices required changing those practices. And that was a price too few physicians and medical groups were willing to pay.

Change, it seems, must be either pain-free or at least less painful than continuing to do business as usual. Since anyone who owns a PC knows technology is not painless, someone — or something — is going to have to make the status quo more painful.

When it comes to delivering pain to other businesses, few can match Wal-Mart. Their ruthless treatment of suppliers in pursuit of lower prices for customers is the stuff of legend. So are many of their other business practices. 

What cannot be denied, however, is that their gravitational pull is so great it distorts any business they enter. And they’re about to enter the medical business.

Wal-Mart is joining the in-store clinic movement. And as  reported by Marianne Kolbasuk McGee in Information Week, “not only is [Wal-Mart] rolling out e-health records to tens of thousands of its own employees and their dependents, … but it’s also requiring the use of e-health record software for patients treated at the in-store [medical] clinics it’s about to launch.” Wal-Mart will also be requiring its clinic operators to use practice management software as well.

E-health initiatives are a part of virtually every health care reform proposal put forward in the past few years. The goal is to reduce physician costs and increase patient safety. Forward movement, however, is nearly as rare as expectations are high. According to Information Week, ”less than 20 percent of U.S. doctors have deployed e-health record systems in their offices ….” That’s far too low to move the industry. But few industries are too large for Wal-Mart to move. Wherever the tipping point for widespread adoption of technology in physician practices might lay, Wal-Mart’s presence and impact is likely to get us there faster.

With Wal-Mart’s ability to drive markets — and to drive down prices — perhaps low cost, but demonstrably proven, technologies may finally be “free enough.”

Public and Private Sectors Facing Tough Health Care Decisions

I’ve written numerous times in this blog on what’s needed to achieve meaningful health are reform: increase access to health care coverage; and constrain escalating medical costs. The latter is the most important. If we don’t get control of health care costs we won’t be able to afford to provide access. Not only that, health care costs will vacuum resources away from other important societal needs.

There’s been some success in recent years on increasing access. The State Children Health Insurance Plan has resulted in coverage for millions of children that otherwise would likely to have gone without. Carriers have created innovative products that have proved popular with young people and those seeking catastrophic coverage. (There’s also been numerous disappointments during that time, when opportunities to expand coverage failed).

In fact, a substantial component of the uninsured could obtain coverage today. As Aetna CEO Ron Williams noted at a meeting of the Business Council in Florida last week, 20 percent of the uninsured are eligible for Medicaid and the state children’s health programs, but fail to enroll in those programs. In an article on the conference by Jason Szep of Reuters, Mr. Williams also noted that 10 percent of the nation’s 47 million uninsured are college students and “could be easily and relatively cheaply enrolled for health care insurance.”

At the same conference, Angela Braly, the CEO of WellPoint, called for expansion of programs aimed at children and low-income families. WellPoint estimates this could cut the uninsured by 25 million if all 50 states acted to cover all children and increasing eligibility for Medicaid.

It’s true that too many of those eligible for public programs fail to enroll in them. It’s true that some states have had success in requiring college students to have health care coverage. And it’s true that expanding children and low-income health programs would bring many of today’s uninsured into the system. The problem, however, is that these programs are under tremendous stress. The safety net that has assured health care for all is crumbling.

In Los Angeles, for example, there are plans to shut 11 health clinics to meet the county’s $195-$331 million budget deficit. According to the Los Angeles Times,  a majority of the Board of Supervisors opposes these closures, but simultaneously, health officials are drawing up contingency plans that would shutter all of the county’s health clinics — facilities that provide “more than 160,000 urgent care visits and nearly 180,000 specialty care visits a year, mostly from the uninsured and poor.”

Meanwhile, in Sacramento, doctors providing care to Medicaid patients will see their reimbursement rates cut by 10 percent as the state makes a mid-year adjustment to its hemorrhaging budget. As a result, fewer physicians are likely to accept new Medicaid patients or some may stop seeing program participants altogether.

America’s current health care system is already a mix of private and public health care programs. The private sector is under attack for its rescission practices, among other issues. The public sector is going broke and, even in the best of economies, seems unable to reach out to all those promised care.

What’s needed is a national dialogue about priorities. If Americans are serious about expanding coverage, they’re going to have to find a way to pay for it in good economic times or bad. And that means keeping it affordable. States should not balance their budgets by breaking their promise to those whom they promised coverage.

The private sector is also going to have to clean up its act. Behaving legally is not enough, they have to act right. Carriers need to act in ways that earns the public’s respect by demonstrating an appreciation of the critical role these enterprises play in society — a role that requires them to meet a higher standard than most corporations. Business as usual could mean no business at all.

There’s a strong demand among voters to change the country’s health care system. Given all that’s happening, that’s not surprising. And, given all that’s happening, it’s not going to be easy, either.

The High Cost of Simplistic Health Care Reform

Representatives Jim Langevin, a Rhode Island Democrat, and Christopher Shays, a Republican from Connecticut, introduced legislation this week to create a nationwide health insurance plan similar to the Federal Employee Health Benefits Program. This is an idea that blossoms every Congressional session like the cherry blossoms near the Jefferson Memorial. There’s an internal logic to the proposal which is compelling: every American should have the same health care coverage as members of Congress.

The concept is similar to the managed competition initiative developed by the Clinton Administration in the early 90’s.  As described by the Kaiser Family Foundation’s KaiserNetwork.org, uninsured residents would be required to enroll in a health plan that meets national standards. Individuals would pay up to 28 percent of the premiums. Employers would either offer their workers coverage or pay up to $12,000 per employee to finance their coverage through the FEHBP-type purchasing pool.

That this kind of reform was introduced — again — isn’t what caught my eye. It’s the potential price tag: $12,000 per employee. A California Employer Health Benefits Survey in 2007 found employers in the state pay monthly premiums of about $374 for each employee. That comes to slightly less than $4,500 per year. Double this real world premium average and the Langevin/Shays proposal still seems to apply a 25 percent surcharge.

Maybe I’m missing something in their formula, but this does seem to point out a problem with overly simplistic approaches to health care reform. They sound good, but don’t always hang together well. And cost is not the only problem. The population served by the FEHBP tends to be well educated and, as federal employees, have a support network to help them make it through the annual open enrollment program. It tends to service a healthier population than the overall country, too. Duplicating that system for the general public won’t be nearly as straightforward as its advocates hope.

Even with all it’s problems — and it’s high cost — the Langevin/Shays proposal should be part of the mix when the next Administration begins to address the nation’s health care system. So should a single payer system. So should health care vouchers and every other idea out there. It’s important for the presidential candidates to explain their approach to health care reform. But once the real work begins, it would be more helpful for the next president to identify the goal and set the parameters, then let all ideas flourish. Even those that are too simplistic for their own good.

Speaker Nunez on Health Care Reform 2008

According to Assembly Speaker Fabian Nunez, there’s no chance of California passing comprehensive health care reform before 2009 — if then. But that won’t stop the legislature from pursuing more narrowly focused  changes to the state’s health care system.

Frank Russo, who publishes the California Progress Report blog, was among those who talked to the Speaker following a press conference on Tuesday at the Sacramento Press Club.  Mr. Russo describes Speaker Nunez as being “quite animated” discussing the headlines that day concerning Blue Cross of California asking physicians to confirm the disclosure of pre-existing conditions on members’ applications (a practice Blue Cross has now discontinued). He quotes the Speaker as blasting the carrier and then promising, “No comprehensive health care package, but reforms to help improve the current health care system—absolutely.”

This is further evidence Senate Bill 840, Senator Shiela Kuehl’s legislation to establish a single payer system in California, is going nowhere this year. The Speaker again promised to subject the measure to the same level of scrutiny Senator Kuehl, as chair of the Senate Health Committee, gave to the Speaker’s comprehensive health care reform package, Assembly Bill ABX1-1. And if by some miracle — or political calculation — SB 840 were to be passed by the legislature, Governor Arnold Schwarzenegger would be certain to veto it.

Instead of comprehensive reform, I expect lawmakers to introduce several elements of ABX1-1. Setting a medical loss ratio target was an aspect of ABX1-1 that resonated with lawmakers — and will be looked at even more favorably in an election year. Bills addressing rescissions and establishing premium rate regulation mechanisms are also certain to emerge. There will be others. Few of these bills, however, are likely to become law. First, not all will pass. If money is a bill’s chances fall to near zero. Second, Governor Arnold Schwarzenegger will look closely at those that do make it through the legislature. During the health care reform negotiations that led to ABX1-1, he demonstrated a firm understanding of how the elements of ABX1-1 related to one another. He will likely be skeptical of a modular approach to reform, reasoning that without the checks and balances contained in ABX1-1, the consequences of a specific reform could do more harm than good.

There’s a good chance California won’t take another shot at comprehensive health care reform even in 2009. The timing will depend a great deal on who wins the White House in November. If a Democratic becomes president, California lawmakers will likely wait to see what progress on health care reform the new Administration can make. If a Republican wins, however, Democrats won’t wait. They’ll assume whatever reforms come out of Washington will be insufficient. The wild card in the timing? Governor Schwarzenegger. He’s termed out of office in 2010. He may want to finish what he started in 2007 while he can.

In either case, health care reform is not going away. Only the location may change.

Candidates Need to Address the Real Health Care Reform Issue: Cost

Senators Hillary Clinton and Barack Obama have agreed to two debates before the critical Ohio and Texas presidential primaries. They’ll face off on February 21st in Austin, Texas and then meet again, just five days later on the 26th, in Cleveland. At both sessions Senator Clinton will go after her rival’s health care plan for failing to seek universal coverage. After all, she’ll remind viewers yet again, universal coverage is a moral obligation of society and a litmus test for real Democrats. Been there. Done that. Now it’s time for a new discussion on health care reform.

Health care reform is complicated, complex and challenging, but at its core it boils down to two issues: access and affordability. Access is actually the easier of the two for politicians to address. Just promise voteres they’ll be covered and, if at all possible, avoid talking about what that coverage will look like. If you must address the benefit package, say it will be similar to”fill in the blank” — Medicare, Medicaid, Congress’ health plan, Canada’s. Everyone will assume it covers what they want it to cover. (How many people know prescription coverage is not covered in most Canadian provinces?)

Controlling skyrocketing health care costs is a lot tougher. But as Congressional Budget Director Peter Orszag has made clear, it’s absolutely critical to the country’s financial wellbeing. Yet the topic makes politicians uncomfortable. They have to talk about voters getting the coverage they need, not everything they want. It means tough choices about what’s the responsibility of the coverage provider (whether it’s a private insurance company or a government agency) and what’s the responsibility of individual Americans. It requires explaining what is driving the costs — not only an aging population and new technologies, but consumer expectations, as well. There was a time when a drug addiction was dealt with by the criminal justice system; now it’s a medical issue. It means addressing America’s life style and pointing out that America’s obesity rate is 30 percent higher than Canada’s. That’s a harsh statement to make when you’re going after the couch potato vote. 

During previous debates, the candidates have gotten a free pass on addressing the issue. They’ve made vague references to how they’d reduce medical costs, but I don’t think there’s been a single follow-up question on the topic.

That should change — and it might. The Austin debate is hosted by CNN. On the channel’s Anderson Cooper 360 Degrees on Tuesday night, the pundits actually acknowledged the importance of addressing health care costs, lamenting the candidates’ failure to address the issue.

Was anyone at CNN watching CNN at the time? It’s a 24-hour news channel. CNN and its competitors have to put something between all those commercial breaks. If getting the candidates to talk about controlling medical costs, make them talk about it. Devote a 30 minute segment to the cost control provisions in the both the Democratic and Republican candidates’ health care reform packages. Ask them what ideas they are they pushing and which ones they won’t even consider. Ask them to discuss rationing. Make them describe the sacrifices they’d ask of Americans.

And those debates? CNN is hosting the one on February 21st. Maybe CNN could bring up this issue then?

There’s no need for CNN’s talking heads to lament the candidates’ failure to address an issue: they have the power to force them to discuss it. And they should.

A Short History of California’s “Year of Health Care Reform”

Over the past several months this blog has attempted to track the trajectory of health care reform in California. I had thought about combing through the various posts and summarizing the history of what happened. Now I don’t have to.  Daniel Weintraub of the Sacramento Bee has written a concise and insightful history of the rise and fall of California’s health care reform efforts. 

No doubt there will be people who disagree with his analysis. Assembly Bill ABX1-1, the compromise legislation that emerged from negotiations between Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, was a complicated bill that went through a convoluted process. But Mr. Weintraub does a good job of touching on the highlights.

Some already have objected to his conclusion, that the bill died in a liberal/conservative crossfire. Yet there’s a lot of truth in this observation. Conservatives locked themselves out of the negotiations by refusing to even talk about potential tax increases. Several liberal groups refused to accept any compromise short of single payer while others on the left refused to accept anything short of premium price controls. Their objections created the framework in which negotiators had to operate. It narrowed their options and flexibility. It led directly to the creation of a bill that was financially unworkable.

California needs to move forward now. It’s first task is to get it’s financial house in order in a manner that does as little harm to existing health care programs as possible. That will be a herculean task. Personally I think any meaningful comprehensive health care reform has to, and will, come from Washington. But if legislators in Sacramento are going to move forward with their pet reforms, they’d do well to read Mr. Weintraub’s short history of the Year of Health Care Reform.

Obama’s Health Care Reform Plan Out of Balance

Senator Barack Obama has been on the defensive concerning his health care reform proposal for much of the past several months. Senator Hillary Clinton and, while he was in the race, former Senator John Edwards pounded Senator Obama for failing to seek universal coverage by mandating Americans to obtain health insurance. If you don’t start off with a plan for universal coverage, Senator Clinton claims in nearly every speech she gives, you won’t get it. She goes further, claiming universal coverage is a moral obligation of the nation and a litmus test Democrats.

Senator Obama counters that Senator Clinton would have to garnish wages to force people to buy coverage. He notes that Senator Ted Kennedy, the dean of Congressional health care reformers, is comfortable enough with the Obama approach to endorse the Senator. Finally, Senator Obama claims his reform package, by lowering  the cost of coverage, will result in Americans getting covered because they will finally be able to afford it.

Unfortunately for Senator Obama, his logic doesn’t hold up to any meaningful scrutiny. Virtually every study done shows Senator Obama’s approach resulting in fewer insured Americans than does Senator Clinton’s. Arguing that they’re equal in terms of “universal coverage” defies logic and experience.

But there’s a worse gap in in Senator Obama’s health care reform plan: his refusal to consider a mandate to buy coverage, coupled with his plan’s inclusion of requirement that carriers sell policies to all applicants, undermines his claim to making coverage more affordable. The carrier mandate (often called “guarantee issue”) raises the cost of insurance unless all residents are required to buy. That’s how New York and New Jersey approached health care reform — carriers there have to sell to all comers, but the purchase of coverage is voluntary. The result: premiums are twice as high in those states than in California.

This shouldn’t come as a surprise. Imagine a system in which homeowners could wait to buy fire insurance until after their house burned down. Or one in which drivers could wait until after their accidents to buy car insurance. The cost of these policies would be astronomical. After all, if consumers can avoid paying a premium until they need the coverage, they’ll wait. That’s not being irresponsible, that’s human nature.

There’s no reason to think introducing this imbalance nationally will produce any other result when it comes to health insurance. Without including both, a mandate for carriers to sell and for consumers to buy coverage, Senator Obama’s plan will increase health insurance costs in spite of other provisions in his reform package.

Senator Obama no doubt is aware of this reality. He may be in denial about it, but he’s bright and so are the people around him. In an ideal world he’d address the imbalance in his health care reform plan now, during the primaries. But doing so would open him to charges of flip-flopping. It would demonstrate that Senator Clinton’s experience dealing with health care reform led her to a more responsible conclusion (at least on this aspect of their plans). Senator Obama might be interested in bringing a new approach to politics, but even he’s not ready to hand his opponent a cudgel on an issue as important to voters as health care reform.

My guess is he’ll wait until after he’s secured the nomination — if he does, indeed, secure it. Then, sometime in the summer he’ll introduce a willingness to consider guarantee issue in combination with an “affordability exemption” to assure it doesn’t bankrupt consumers. And if it doesn’t happen during the campaign, guarantee issue is certain to find its way into his Administration’s reform package.

If Senator Obama is lucky, Senator Clinton will continue to level only the “lack of universal coverage charge” against him. That line of attack is getting old, but she seems unwilling to abandon it, even though she’d be far better served by forcing Senator Obama to defend an indefensible imbalance in his plan.