America’s Disappearing Common Ground

Everyone knows the reason so little gets done in Washington is that the two political parties have become ever more divided and uncooperative. We can see it on cable news programs. We can hear it on talk radio. And we experience it as the federal government generates more crises than solutions. We also experience it every Thanksgiving dinner when our crazy uncle starts spouting eye-roll inducing political nonsense.

For those of us engaged with health care reform, we witness this dynamic every time politicians on both sides of the aisle identify the same problem, but refuse to work together to resolve it.

Subjectively, we all know common ground is shrinking in this country. Turns out there’s objective evidence, too. The Pew Research Center tracked the distribution of political values held by Democrats and republicans between 1994 and 2014. As the graph below shows, the gap is widening.Pew Ideological Divide Graphic

There’s a couple of things to note in the graph. First, the gap between the center of each party is further apart now than 20 years ago. The second is the bulking up of the extremes. “92% of Republicans are to the right of the median Democrat, and 94% of Democrats are to the left of the median Republican”. This shows what we’ve all felt: the parties have moved apart and common ground is increasingly rare.

The Pew study was issued more than a year ago. However, anyone watching this year’s presidential debates will attest that ideological differences between the parties is definitely not diminishing.

America moves forward when reasonable people can disagree, find common ground, and compromise. Over the past 20 years, however, fewer partisans see the other side as reasonable; fewer are willing to compromise. Common ground is disappearing.

The Pew Study is pretty depressing for those of us who want less fighting between the parties and more problem solving. However, there is some good news in the report. While there’s movement towards the extremes, the majority of Americans remain neither uniformly liberal nor conservative. As the Pew Research Center notes, “more [Americans] believe their representatives in government should meet halfway to resolve contentious disputes rather than hold out for more of what they want.”

Politicians often claim to speak for the “silent majority.” This is usually not the case as it’s their next statement is often a pander to the most extreme elements of their party. The real silent majority are those who want their representatives to “meet halfway.”

The problem is, however, the silent majority is, well, silent. No one hears them. In a political context, silence equates to voting. If it’s the extremists who vote, then politicians listen to the extremists. When a majority of Americans stand up and insist that their representatives work together, politicians will find a way to work together. Maybe not right away, but eventually they’ll get the message.

Until the majority speaks up (votes), however, it’s the crazy uncles that are listened to–and not just on Thanksgiving. In fact, it seems the crazy uncles are part of the presidential debates now, too.

Health Care Reform Absent from Democratic Debate

Two hours of policy-heavy dialogue and, unless I missed it, not one of the five Democratic candidates for President uttered the words “Obamacare,” “Affordable Care Act” or “health care reform.” True, Senator Bernie Sanders brought up “Medicare for all” and declared that health care coverage is a right of citizenship. However, there was no mention of his remarks by the other candidates, former Senator Lincoln Chafee, former Secretary of State Hillary Clinton, former Governor Martin O’Malley, and former Senator Jim Webb.

Update: October 14, 2015: Oops. There was a brief discussion of allowing undocumented immigrants eligible for coverage under the ACA. The focus of this segment was immigration and the candidates mention of health care was incidental. I don’t think this undermines the point of this post, but they did mention it. My bad.

Ignoring health care reform is a s pretty amazing development when you think about it. Health care reform was a big part of the Democratic presidential primary campaign in 2008. The passage of the Patient Protection and Affordable Care Act in 2010 turned American politics upside down adding copious amounts of fuel to the Tea Party movement. Yet, in the CNN/Facebook debate from Las Vegas … not a word.

I’m not saying CNN should have made health care reform the primary topic of Tuesday night’s Democratic debate. However, a short simple question soliciting short simple answers would have, I believe, highlighted some differences among the candidates. At the very least it would have contrasted the Democrats running for president from the Republicans seeking the office.

My hoped for question: “What changes to the Affordable Care Act, if any, would you seek if elected President?”

We know Senator Sanders’ response: he’d scrap the Affordable Care Act for a single payer system. Would any of the others join him? Maybe. Would any of them defend the health care reform law as is? Possibly. Quizzing the candidates on legalizing marijuana was of interest to some, no doubt, but, in my mind at least, finding out what they’d change in the ACA is both a more important and fascinating topic.Of course, given the topic of this blog, I am a bit biased.

Jeb Bush Reveals Health Care Reform Plan

Ironically, this is the day former Republican presidential candidate, Governor Jeb Bush, detailed his health care reform proposal. Calling the ACA a “monstrosity,” Governor Bush said the government should help Americans obtain catastrophic coverage (albeit with a preventive care component) to protect them from financial ruin, but not force individuals to buy and businesses to offer comprehensive coverage.He would require carriers to cover insured’s pre-existing conditions for individuals who maintain continuous coverage.

Under Governor Bush’s proposal, individuals without employer coverage would receive tax credits allowing them to buy coverage against “high cost medical events.” Governor Bush also called for raising the contributions limits allowed on health savings accounts.

Significantly, Governor Bush recognizes that the ACA can’t simply be repealed without serious adverse impacts on what he calls “the 17 million Americans entangled in Obamacare.” He calls for a transition plan to help them move from the ACA to the Governor’s system.

Governor Bush’s health care reform plan also calls for restoring state regulation of insurance markets, promotion of health information technology adoption, wellness rewards and innovation in care delivery models. An interesting, and maybe wishful, provision of his proposal is “an app on your smart phone that calls your doctor to your front door, just as it does for a car to come pick you up.”

Maybe Next Time

Health care reform in general and the Affordable Care Act will no doubt be a big part of the general election. Governor Bush has laid out one approach for Republicans. It would be nice to learn a bit more about what Democrats would do. CBS hosts the next one on November 14th. Maybe the issue will come up then.

Is requesting one straightforward health care reform question asking for too much?

 

Health Care Reform the 2016 Where’s Waldo

At this time in 2011, six months before the Iowa caucuses, health care reform was a big deal. Republicans couldn’t see a live microphone without calling for its repeal. And one would think that the official name of what was commonly referred to as “Obamacare” was “the President’s signature issue” in his first term. Flash forward four years and health care reform is now the “Where’s Waldo” issue of 2016: it’s there somewhere, but darn well hidden.

True, every candidate on the GOP wants to repeal the Patient Protection and Affordable Care Act. They are all happy to haul out the old tropes about how the ACA is a job killing, anti-free market, mess and a government overreach. Many will be happy to explain how it’s all unconstitutional.

Meanwhile, every candidate on the Democratic side is defending the ACA, although some more enthusiastically than, well, at least one. Candidate Bernie Sanders has promised to introduce “Medicare for all” legislation (a euphemism for single payer) soon and would seek a single payer solution were he to become president. Yet even on the Democratic side, the topic of the ACA is pretty well hidden in their campaigns.

In fact, a quick survey of campaign web sites shows a remarkable lack of emphasis on health care reform by presidential candidates. On the Democratic side, health care reform doesn’t make the issues list on the campaign web sites of former Governor Martin O’Malley or Senator Bernie Sanders. Defending the Affordable Care Act is the ninth issue addressed by former Secretary of State Hillary Clinton’s web site.

On the Republican side Donald Trump is too busy bullying his opponents and the press to mention any issues other than immigration on his site. Health care reform makes Dr. Ben Carson list of issues, but he devotes just 98 words to the topic — and the only alternative he mentions is his support of health savings accounts. Former Governor Jeb Bush’s site is nearly issues free (there’s a white paper on his tax reform plan in the “news” section, but there is no “issues” tab). I couldn’t find anything about health care reform on the site. Then, I couldn’t find the issue (or any issues) on Carly Fiorina‘s or Senator Ted Cruz‘s sites, either.

Governor Scott Walker announces his intent to repeal Obamacare on his first day in office. And although I couldn’t find it on his web site, to his credit Governor Walker has offered a plan to replace the ACA. Senator Marco Rubio gets around to discussing health care reform on his web site after first mentioning 17 other issues while on Governor John Kasich‘s site it comes in at #3.

Given all that’s going on the world, it’s not surprising health care reform isn’t a driving issue. Which is remarkable. Health care reform arguably gave birth to the Tea Party movement. It cost Democrats the majority in the House in 2010 and helped chip away at their Senate majority until that was lost, too. In short, health care reform moved elections.

Now, not so much. The ACA is a part of America’s landscape now. Too many people are insured under the law to repeal it. Too much physical, digital and process infrastructure has been built out. Too many stakeholders are vested in the ACA continuing and opponents of the reforms have no coherent program to replace it.

This isn’t a bad thing. Because it opens up a real possibility that, once there’s a new President and Congress in 2017, they can accomplish something important: fixing the Affordable Care Act. The law has lots of flaws, but the debate since it’s passage has too often been an all-or-nothing affair: dump it or defend it. Yes, there’s been some tweaking around the edges of the legislation, but not the comprehensive review and modification that’s needed.

Finding Waldo can be hard. Finding a way forward to improve the ACA will be harder still. If little kids can find Waldo, perhaps there’s hope that what passes for adults in Congress can find common ground to improve the ACA. That’s still a long shot, but perhaps a bit more possible now than just a year or two ago.

Initial Response

It’s going to take some time to dive into the Supreme Court’s 5-4 decision on the constitutionality of provisions of the Patient Protection and Affordable Care Act. The opinion is now online for those who wish to wade through it. Here’s my initial take:

1. As noted in my first post today, the individual mandate isn’t much of a mandate, but the principle of a mandate could have brought down the entire health care reform package. It didn’t, but that doesn’t mean the individual mandate, as written, will have the impact supporters of the PPACA intend. The only thing that’s new today is that this provision of the law can now be described as a “tax.”

2. Chief Justice John Roberts makes clear that he believes an individual mandate would violate the Commerce Clause. However, because he interprets it as a tax, that observation is important, but doesn’t effect the outcome. The other four Justices in the majority (Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan), in a separate opinion, stated their belief an individual mandate is constitutional. However, in order to form a majority they’ve signed off on Chief Justice’s Robert’s interpretation. So while having four members of the Court interpret the Commerce Clause this way is significant to legal scholars and could impact the future, for now it’s immaterial.

3. The four Justices dissenting from the majority opinion (Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito) would have found the entire PPACA unconstitutional. Chief Justice Roberts often sides with this group of colleagues. He made history by parting ways with his more conservative colleagues. Justices might have lifetime tenure on the Court, but it still took courage for the Chief Justice to make this decision.

4. Politically, this decision is a two-edged sword for both presidential candidates. The Administration’s key domestic accomplishment has been upheld. The Administration can now move forward to implement the health care reform package without the cloud of court decisions making their work meaningless. But the President’s key domestic accomplishment is also one of his greatest liabilities in the upcoming election. The PPACA remains unpopular. Many Americans (including four Supreme Court Justices) believes it’s an unwarranted expansion of federal power at the expense of personal liberty. This decision will only flame the passions of those who take this view, meaning they’ll be going to the polls in November with one goal in mind: elect a President and Congress that will repeal the PPACA. Will supporters of the bill be as motivated and engaged? Not likely.

5. Just because the PPACA is constitutional does not mean we’ve seen the final version of the law. Congress will amend health care reform. Agencies (both federal and state) will interpret it. The PPACA is complicated and open to significant interpretation. The upcoming election will determine how much the law will change, not that it will be changing.

6. The PPACA accomplishes a lot of good things: increases access to coverage, provides some useful and meaningful consumer protections, takes the first steps needed to begin constraining health care costs, and more. The PPACA also botches a lot of important things: it will not make coverage more affordable, it doesn’t go far enough to constrain escalating health care costs, and more. Lawmakers owe it to their constituents to revisit the law and make some substantial changes. This doesn’t mean Democrats have to follow the GOP’s demand to repeal the law nor does it mean Republicans have to cave to the administration. But both sides need to recognize that the PPACA is the law of the land. Barring a GOP super-majority in the Senate come 2013, the PPACA is not going away. So responsible leaders will try to make it the best law possible.

7. The Court majority made clear an individual mandate is not justified by the Commerce Clause or the Necessary and Proper Clauses of the Constitution. This will have an impact on other social welfare efforts Congress might consider. Needing to fund expansion of the safety net through taxes is a tough political and practical challenge.

8. However, there were four votes to uphold the PPACA under the Commerce Clause. Which underscores the importance of this November election. Presidents appoint Supreme Court Justices. All of the Justices four of the Justices upholding the law under the Commerce Clause were appointed by Democrats. All four of the Justices voting seeking to overturn the law were appointed by Republicans. The Chief Justice shows that not every appointment votes in the way one would expect based on the party of their appointing President. And two of the liberal Justices joined with conservatives and agreed that the Medicaid expansion included in the PPACA was unconstitutional. But the fact is, the appointments of Republican Presidents tend to be more conservative; those appointed by Democrats tend to be more liberal. At least one, and maybe more, vacancies will open on the Supreme Court in the next four years. Who is President matters.

9. The Supreme’s decision on the Medicaid provision of the health care reform law will be interesting. In essence, a 7-2 majority said the law went too far in threatening to withhold Medicaid funding to states who refuse to expand Medicaid eligibility to those at up to 133% of the federal poverty level. They ruled the federal government can withhold the additional funding promised in the PPACA to pay for this expansion, but they can’t take all Medicaid funding away from non-participating states. Put another way: states have the ability to opt out of the Medicaid expansion. Given the importance of this expansion to reduce the uninsured, this is an issue President Obama and his allies in Congress will need to address. As noted above, the health care reform debate is far from over.

10. While watching the news about the decision, an ad by Concerned Women for America with a vicious (and somewhat inaccurate) attack on the PPACA aired on CNN. The upcoming election will be about the economy, but health care reform will be a major factor as well.

7. People who predict what the Supreme Court is going to do and how they are going to do it are making wild guesses. Pundits take another blow.

So, I don’t pretend to have any special insight on the meaning of the Court’s decision today. But my mother misses these posts so I thought I’d return to the keyboard again. I’ll try to write a more thoughtful piece later today or in the next few days. In the meantime, please let me know your thoughts on all this.

And the Winners Are … Maybe

According to SCOTUSblog, the winners are the Patient Protection and Affordable Care Act, the administration of President Barack Obama and the individual mandate … as a tax. But as Amy Howe of that blog notes “It’s very complicated, so we’re still figuring it out.” Chief Justice Roberts joined with the more liberal members of the Court to find the individual mandate (such as it is) constitutional.

So, bottom line: the PPACA is upheld. Yes, the Medicaid provision that allows the federal government to terminate state’s Medicaid funds if they fail to expand coverage to 133% of the federal poverty level is limited a bit through a strict reading of the provision, but the bottom line is the bottom line: the PPACA

The sky is not falling as of yet. The Republic survives. And the Chief Justice, appointed by President George W. Bush (not Justice Anthony Kennedy) is the swing vote. Few predicted that one.

The critical quote, again as reported by SCOTUSblog (which, really, anyone reading this as it’s written should just move over to that site) is “Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.” Section 5000A being the individual mandate.

Is Taxing Health Care Coverage on the Way?

Ideas percolate through the political process in interesting ways: editorials in authoritative publications, important speeches, and more recently, blogs.

For example, the Director of the Congressional Budget Office maintains a blog and it includes an entire section concerning “Health.” The CBO will have a great deal of influence on the health care reform debate. They will provide the benchmark analysis of whatever plans emerge. What they’re thinking matters and, presumably, what their Director is thinking is what the agency is thinking.

For example, former CBO Director, Peter Orzag, now the Director of the Office of Management and Budget, have long warned of the need to reign in health care costs. According to Jonathan Cohn, writing in the New Republic, Mr. Orzag was one of those within the Obama Administration pushing hard for addressing health care reform now, as opposed to later. Clearly what the budget folks think matter. To gain an insight into Mr. Orzag’s thinking, the CBO Director’s Blog is a good start.

The same holds true for the thinking of the CBO’s new director, Douglas Elmendorf. Consider his recent post concerning reigning in medical care costs. In it he notes that “a substantial share of our national spending on health care contributes little if anything to overall health.”  He calls for providing incentives to control costs and sharing of information concerning the effectiveness of treatment. Then he makes an interesting comment: “… the current unlimited tax exclusion for employment-based health insurance dampens incentives for costs control. Those incentives could be changed by restructuring the tax exclusion in ways that would encourage workers to join health plans with higher cost-sharing requirements and tighter management of benefits.”

This opens up a host of interesting worm-filled cans. During the presidential campaign, Republican Senator John McCain called for taxing the value of health care coverage (along with offsetting tax credits). The Democratic nominee, now President Barack Obama castigated the idea, calling it the biggest tax increase on the middle class in history. However, many in Congress of both parties are reviving the idea. OMB Director Orzag has indicated that all ideas, even taxing the value of health care coverage, needs to be on the table. Few other comments on the topic have been forthcoming from the Administration, but realistically, paying for the cost of universal coverage will require at least a strong look at this revenue option.

On the surface, this makes a lot of sense. The current system is regressive, meaning it is a better deal for the wealthy than for lower income Americans. The higher your tax bracket and the richer your benefits, the better the current system works for you. For example, a CEO earning $500,000 a year, paying an effective tax rate of 40 percent (state and local) and receiving health insurance benefits worth $10,000 per year. If the coverage was taxed, our hypothetical CEO would pay $4,000 in taxes. Instead, she gets a “gift” from the tax code of this amount. Working for this CEO is a clerk, earning $40,000 per year and paying 15 percent in taxes with the same coverage. If the value of health insurance was taxed the employee would pay $1,500 in taxes — his gift is less than half of the CEO’s.

You might think Democrats would be jumping all over this loophole. After all, they’re the party of progressive taxes. Instead, those few who are willing to raise the issue are demonstrating real political courage. Because unions, who contributed millions of dollars and armies of foot soldiers into the election of a Democratic Congress and President, are adamantly opposed to taxing benefits.

For decades, unions have negotiated rich health care benefits for their members in lieu of salary increases. Their members valued the coverage, which was received tax free. It was a reasonable trade-off for employers — they can deduct the cost of health insurance just as easily as they deduct the cost of salaries. Changing the rules of the game would, in essence, punish union members for doing what economists say everyone should do: pursue economic self-interest based on the rules of the game.

There are ways to mitigate the pain unions will feel if health insurance is taxed. As Mr. Elmendorf notes, the tax rules can be modified rather than eliminated so as to encourage consumers to choose cost effective plans. Or the value of union negotiated health benefits could be exempted from the tax for a transitional period, allowing unions and employers to negotiate new contracts under the new rules.

Health care reform is going to be expensive — covering all Americans will cost over $1 trillion. We’re already spending large sums to salvage the tattered economy (and, apparently, to enrich the AIG traders who helped get us into this mess). Yes, the government can print the dollars it needs, but that leads to another problem which goes by the name of  inflation.

If health care reform is going to be enacted in the next 12-to-18 months, which I think it will, the money for reform will need to be identified. My guess is taxing health care coverage will be one of those sources. It won’t be a straight repeal of the current exemption, it may be offset with subsidies and credits, some coverage may be grandfathered for awhile, but the tax is coming. 

Meaningful health care reform will change a lot of the rules we’re used to. This is just one of them.

President Obama and Health Care Reform Expectations

Senator Barack Obama remains a Senator for another 77 days. Then he becomes President of the United States. His is a remarkable story heightened by his ability to both symoblize and articulate hope. The challenges he will face upon assuming office are daunting, to say the least. Then there’s the expectations.

Every political campaign is about expectations. Candidates make promises because voters want to know what to expect. Democrats and Republicans, Mavericks and Insiders, they all make promises, which means they all create expectations. In this election, both candidates raised expectations that the nation’s “broken health care system” would, at least, be fixed.

I believe there will be comprehensive national health care reform in the next four years. There’s clearly pent-up demand in Congress for change. A bi-partisan group of Senators led by Democratic Senator Ron Wyden and Republican Senator Bob Bennett already have introduced a comprehensive health care reform package, the “Healthy Americans Act.” Senator Edward Kennedy is looking to cap his historic tenure in Congress with health care reform. While battling brain cancer he and his aides have been meeting (both personally and by video conference) lawmakers and advocacy groups to create a framework for health care reform. Many in Washington believe that the Clinton Administration squandered a unique opportunity for reforms that would have greatly benefited the nation over the past 14 years. They do not intend to let another chance go by.

Health Access outlined several reasons for progressives to be optimistic that meaningful reform is coming from Washington, D.C. They note the starring role health care reform played in Senator Obama’s campaign and the Obama/Biden ticket’s endorsement of Health Care for America Now!’s principles. They point out Senator Obama’s resounding victory will give him the political muscle, and his campaign theme and image gives him the credibility, to push through meaningful reforms.

I believe Health Access’ analysis is correct. There’s another reason health care reform is likely: the Obama Administration will take a far different approach than that taken by the Clinton Administration in 1993. They’ll learn from President Clinton’s mistakes. They’ll be far more inclusive and more accepting of input from Congress. They’ll be more willing to compromise on specifics to achieve their principles.  President Obama will bring to health care reform the same superb organization and discipline he brought to his campaign. All of this bodes well for some kind of significant reform coming out of Washington in the next four years.

The Obama Administration will face two challenges in fulfilling the health care reform expectations. First is the complex nature of the problem. A great deal of the upcoming debate will be spent on market reforms (should insurers be required to sell coverage to all applicants?) and access (should all Americans be required to have health care coverage?). These questions alone have brought down many a reform proposal. Yet they’re the relatively easy challenges. Too little attention will be spent on the most vexing problem facing every health care system in the world: the skyrocketing cost of medical care.

Someone has to pay for health care and there are only three sources: taxes, premiums or charity (some people pick up the tab for other people). Medical care inflation historically outpaces general inflation and there’s no reason to believe that will change. Which means it’s only a matter of time before the burden of paying for care crushes every and all of those sources.

This isn’t news. Last year the Henrey J. Kaiser Family Foundation released a study, Health Care Costs: A Primer, that put the discrepancy between inflation rates in perspective. There have been sporadic attempts in Washington to draw attention to the cost issue. In November 2007 the Congressional Budget Office identified the need for policy makers to focus on restraining health care costs. There are a lot of suggestions for controlling medical cost problem floating around. Few of them are easy to implement, especially since numerous interest groups will work hard to defend their current share of the health care dollar. And in the end, for better or worse, health care reform comes down to dollars.

Which leads to the second problem facing President Obama’s health care reform efforts. The nation’s economic house is in disorder. Can the nation afford expensive health care reform during a time of financial crisis?

Well, it depends. If health care reform is viewed as a line item expense on the government’s ledger, the answer is no. Even a liberal Congress is going to be hesitant to run up ever greater deficits by increasing government spending. And it’s not yet clear this Congress will be more liberal than the last. After all, a lot of its newer members came from relatively conservative districts or states. Especially when it comes to budget matters like deficits and taxes, the new Congress may have swing toward the middle.

But spending money on the health care system need not be viewed as a simple expense. By repositioning health care reform as part of a public works-like stimulus package the huge costs involved may be more palatable to the public and fiscal hawks in Washington. President-elect Obama has already declared his desire to increase spending on the nation’s infrastructure in order to create jobs and bolster the economy. Infrastructure is usually defined as roads, bridges and buildings. That doesn’t mean the definition can’t be expanded to encompass the health of its work force. In this context, health care reform is not a cost, it’s an investment.

President-elect Obama has promised voters health care reform during his first term. Upon taking office, however, he’ll face wars abroad and economic crisis at home. Dealing with the latter does not require him to ignore the former issue. By positioning health care reform as part of his plan to rebuild America, he might actually be able to fulfill the great expectations he’s created.

Roundup: McCain and Obama Health Plans

As a quick search will reveal, I’ve expressed my vieaw of the presidential candidates’ health care reform plans in several posts over the past few months. Put simply, my belief is that the proposals by Senator John McCain and Senator Barack Obama are both grievously flawed. The winner on November 4th would be far better served repositioning their ideas as a statement of philosophy, principles and concepts rather than a blue print for change. The incoming president should then start with a blank slate and come up with something that might actually to more good than harm.

But that’s just my take on their plans. I thought it might be interesting to pull together in one post links to what others are saying about the plans. I’ve tried to find opinions and blogs from across the political and policy spectrums, but if you think I missed an important perspective, please let me know by writing a comment and providing links of your own.

To get things started, here’s a quick comparison of the McCain and Obama health care reform plans. The Commonwealth Fund offers a more detailed review.

  • John Goodman takes both plans to task (my thanks to Ron Masters for bringing this one to my attention).
  • This post on the Harvard Kennedy School’s site, describes all things wonderful about Senator Obama’s proposal.
  • The PatientAssistanceblog finds things to like in Senator McCain’s plan.
  • The American magazineaccuses Senator Obama of seeking to end private health insurance.
  • The Lewin Group prices out the costs of both plans (such estimates should be taken with huge quantities of salt as another, equally respected group can come up with far different results. It’s sort of similar to why polls differ to much. It’s all in the assumptions.)
  • The Physicians for a National Health Program are advocates of a single-payer health care system. They don’t like either proposal.
  • Voters desire for significant health care reform is noted over at MedPage Today.
  • Richard Locker of the Commercial Appeal (a paper in Memphis) agrees with me that the candidate’s proposals are merely starting points expressing their attitudes toward health care reform. He also explains why many think substantial change is unlikely to emerge from Washington any time soon.

This is far from being an exhaustive list. I’ll probably add more between now and election day and, again, I hope you’ll add to the list by leaving a comment, too.

Obama Must Do Better on Health Care Reform

In his stump speech, during the presidential debates, highlighted in his 30 minute commercial, Senator Barack Obama has made clear that, were he elected president, health care reform will be near the top of his priorities. It’s viewed as a critical component in fixing the nation’s faltering economy, ranking alongside energy independence and a middle class tax cut at the top of his domestic agenda.

Senator Obama’s commitment to the issue is more than ideological, although he does see health care coverage as a right of all Americans. It is also highly personal. Senator Obama described the roots of his committment to health care reform in Sarasota, Florida yesterday this way: “And as somebody who watched his own mother lying on a hospital bed at the end of her life because they had cancer. The insurance companies were saying this was a pre-existing condition, maybe we don’t have to pay for your treatment, I know what it’s like to see a loved one suffer not just because they’re sick but because of a broken health care system.”

This combination of ideology, politics and the personal will assure that health care reform would be taken up early in an Obama Administration. Given his passion for the issue, the state of the economy and the real need to address serious problems in the current health care system, the odds are extremely high a comprehensive reform package will emerge sometime in his first term. Whether these reforms will be similar to what Senator Obama describes on the campaign trail, however, is, fortunately, both uncertain and unlikely.

One reason is because Senator Obama’s health care reform plan is seriously flawed. To cite just one example, a core attribute of his proposal is to require carriers to except all applicants for coverage without regard to their medical condition. As he put it in Sarasota, “… when I am president, we will end discrimination by insurance companies to the sick and those who need care the most.” This is a noble purpose, but if done wrong, it can lead to a health care reform surcharge that would increase the number of uninsured in the country while increasing costs in the system. The “wrong” way is require carriers to sell coverage without requiring consumers to purchase it. This, in essence, is how non-employer sponsored coverage works in New York and New Jersey. Average premiums in those states are more than twice what they are in California

The need for matching mandates, was integral to Senator Hillary Clinton’s health care reform plan. She perceived it more as a means to universal coverage, but also acknowledged that “adverse selection” is a real, proven phenomena. Imagine the premiums auto insurance companies would need to charge if drivers could wait until after an accident to buy automobile insurance. That is adverse selection and it is exactly what Senator Obama is proposing.

Another reason Senator Obama’s health care reform proposalis unlikely to survive the legislative process intact is it will need to compete with a host of other plans. Senator Ron Wyden (a Democrat) and Senator Bob Bennett (a Republican) have brought together a bipartisan coalition of Senators behind the “Healthy Americans Act.” Then there’s the proposal by Dr. Ezekiel Emanuel, Director of the Clinical Bioethics Department at the National Institute of Health, who proposes a voucher system financed by a Value Added Tax and shares some elements of the Wyden-Bennett proposal. Senator Ed Kennedy is talking to Senators and policy mavens from across the political spectrum to develop a reform package he hopes to introduce in January. Republicans, too, have a host of ideas for reforming the nation’s health care system. Some might even look similar to the health care reform package advocated by Senator John McCain during this presidential campaign.

In short, there will be no dirth of ideas when Washington begins to address health care reform in 2009. Hopefully a coherent, workable plan will arise from this stew of policies and concepts. Senator Obama speaks of being open to other approaches. As he put it when speaking at a Families USA forum in January 2007, “… affordable, universal health care for every single American must not be a question of whether, it must be a question of how. We have the ideas, we have the resources, and we will have universal health care in this country by the end of the next president’s first term.”

As president, Senator Obama would do well to remember these words. There will be pressure to pass something and pass something quickly. The “First 100 Days” nonsense will be pushed forward as his only window for pushing through comprehensive reform. This is silly. It’s far more important to get health care reform done right than according to an arbitrary timetable.

Instead of rushing reform, President Obama should demand that all the “hows” be on the table. He should require participants to leave their egos and pride of authorship at the door. He should demand an honest appraisal and accounting of both what’s working and what’s not working in the current system. He should set forth the principles he expects to achieve in the process. Then and only then should the hard work of building a new, better system, one that will provide “affordable, universal health care for every single American” begin.

Yes It’s the Economy, But It’s Health Care Reform, Too

In 1992, James Carville wrote down the key messages then Governor Bill Clinton’s campaign had to focus on in order to win.

  1. Change versus more of the same
  2. The economy, stupid
  3. Don’t forget health care

Throw in a cup of national security and you’ve got the same recipe for presidential success in 2008. Anyone listening to a speech by Senator John McCain or Senator Barack Obama will appreciate that their campaigns understand this reality. And given the recent credit crisis and financial maelstrom, the economy has become an even more central part of this election. In interpreting the public’s demand for change, however, the dominant position of economic issues should not hide the fact that voters want health care reform, too.

According to the October Kaiser Health Tracking Poll, no surprise here, the economy is overwhelmingly, the most dominant issue in this year’s campaign. 62 percent of the survey’s respondent’s listed the economy as “the single most important issue in [their] vote for president.” 13 percent of the respondents cited Iraq while 12 percent named health care.

Economic concerns emerged as the key issue long before the current financial crisis, however. In the December 2007 poll, Iraq was the top issue, with 30 percent of the respondents listing it as the most important issue. It was followed by the economy at 23 percent and health care at 21 percent.

In February 2008, the economy had moved into first place, having been named by 43 percent of respondents. The percentage name Iraq and health care as the most important issues remained constant at 29% and 21 percent, respectively.

By August 2008 49 percent of respondents were citing the economy as their top issue while Irag had dropped to 25 percent and health care to 16 percent. The Kaiser survey interviewed “likely voters” by phone between October 8th and October 13th, well after the economic crisis had set in, making the big change in the results understandable.

One might conclude from this that health care reform is moving off the public’s radar as a salient issue. That would be a mistake. The Kaiser survey shows that 75 percent of Democrats and 61 percent of independents believe “it is more important than ever to take on healthcare reform.” Even 42 percent of Republicans agreed with this statement. What it shows is that health care reform and economic security are intertwined and inseparabe. A key aspect of “fixing” the economy will involve “fixing” health care.

According to the Kaiser study, 35 percent of respondents themselves or a family member had put off getting health care they needed because of the economy. 31 percent said they skipped recommended medical tests or treatment and 27 percent said they didn’t fill a prescription. 28 percent of the respondents reported they had problems paying for health care and health insurance as a result of recent changes in the economy.

Restoring consumer confidence is a substantial part of recovering from economic set backs. So it is significant that half of the respondents (51 percent) said that “lower prices for health care and insurance would make a big difference in their family’s financial situation.” That’s more than the 45 percent who said a rebound in the stock market would make a big difference in their situation.

Senator Obama has cited health care reform as one of the top three issues he’ll address as president. There are numerous plans already circulating in Congress to jump start the reform process, including a bipartisan health care reform package backed by 12 Senators, six from each party. Senator Ted Kennedy, who is at home battling brain cancer, is talking with lobbyists, policy mavens and lawmakers from both parties to develop a framework for health care reform for the new president. Senator Kennedy intends to introduce his legislation as soon as the new Congress convenes.

So yes, the economy will be the dominant issue between now and election day. And it will dominate the president-elect’s wait to move into the White House and it will dominate his first months — perhaps his first term — in the oval office. The economy will dominate, but it won’t eliminate other issues. The American people expect health care reform to be among those other issues — and it will be.

What may surprise some is how quickly the health care reform effort will get underway. My guess is the new president will give a major address on the issue before inauguration day. Health care reform is simply too tied to the reality and perception of Americans’ economic security. It’s too important to Senator Kennedy. It’s too important to helping businesses recover and grow. The American people want the new president to address health care reform. And the new president will need to.