Individual Health Insurance to Get Federal Scrutiny

Over 17 million Americans purchase health insurance for themselves and their families. Of the 47 million Americans uninsured during any year, academics project that six-to-twelve million could afford coverage, but either cannot obtain it due to their health conditions or choose not to purchase insurance. For argument’s sake, let’s say the market for self-purchased policies — generally referred to as individual coverage or, sometimes individual and family coverage — is around 20 million Americans.

That’s a substantial market. For years, however, it was mostly ignored. To be sure, consumer affairs and financial writers would publish their annual article on how to buy health insurance you’re self-employed. And health insurance agents certainly talk about the product. But for most people, the difference between individual and group coverage was of no interest. It was all “health insurance.”

That’s changing. First, because Senator John McCain and others, mostly Republican lawmakers, want to shift the nation’s health care system from one built around employers to one centered on individuals. Senator McCain’s health care reform plan calls for allowing “individuals to get insurance through any organization or association that they choose: employers, individual purchases, churches, professional association, and so forth.”

The second reason for greater attention being focused on individual insurance is the result of how some insurance companies have reacted to current market realities.  Since purchasing health insurance is voluntary, insurance companies need to protect themselves from those waiting until they’ve got claims in hand before buying. This means they require a health history from all applicants and accept only those posing an “acceptable risk.” In other contexts this behavior is understandable. No one expects auto insurance companies to sell coverage after an accident. No one expects insurers to sell a fire insurance policy after the house has burned down. Yet, surprisingly, many consumers — and policy makers — seem to believe that requiring insurers to sell medical coverage to individuals who have already scheduled their surgery is both financially and morally sound.

Some states, such as New York and New Jersey, require insurers to guarantee issue coverage to all applicants regardless of their health condition. Consumers in New York and New Jersey also pay premiums costing on average twice as much as those in Californians. But some carriers went beyond screening out high risks at the time they applied for coverage and instead sought to terminate the coverage when they used their insurance. The aggressive rescission practices of these carriers earned insurers tremendous criticism and ill-will.

The convergence of these two factors: the presumptive Republican presidential nominee seeking to expand the individual market and abusive rescissions by some carriers can have but one result: a Congressional inquiry. Democratic House Committee Chairmen John Dingell, Henry Waxman, and Frank Pallone have asked the Government Accountability Office to investigate the state of the individual health insurance market. They have also asked the GAO to look into the operation of state high risk pools which offer coverage to those unable to obtain private insurance.

In making their request, the Congressmen stated “The individual market for health insurance coverage is seriously flawed. Many people who need insurance and apply for it are denied coverage in the individual market or are offered insurance coverage that turns out to be inadequate or it is too expensive or both.” If this sounds like they already know what the GAO investigation will uncover, well, they do.

This makes the results from this Congressional involvement relatively easy to predict. Insurance company CEOs will be required to testify under oath concerning their rescission practices. The Committees will determine that the current individual marketplace underserves consumers by excluding those with existing medical conditions. And while the high risk pools are serving an important purpose, the committees will determine their coverage is too barebones and too expensive.

Next will come a call for guarantee issue in the individual marketplace and, if Congress is serious about real reform, that will mean a call for requiring that all Americans obtain coverage. And that, in turn, means a health care reform package similar to what’s being put forward by Senators Hillary Clinton and Barack Obama — and it might even be acceptable to a President McCain.

Of course, just because what’s coming is predictable doesn’t mean it’s wrong. It just means change is coming, regardless of who is elected president.

Senator Invites Carriers to Help with Health Care Reform

A coalition of Senators is waiting to help the next president forge a bi-partisan coalition on health care reform. A leader of the group, Senator Ron Wyden of Oregon, spoke before the America’s Health Insurance Plans 2008 National Policy Forum on March 5th and urged health plans to join the effort, not to fight it.

The 12 Senators, six Democrats and six Republicans, have their own health care reform proposal before Congress, the Healthy Americans Act. None of the Senators support every element of the package. But the mere existence of a bi-partisan coalition surrounding health care reform will give the next president a boost in developing a compromise plan.

In Senator Wyden’s address to AHIP, he said the “success of health care reform hinges to a great extent on how your profession responds to the efforts of a new president and a new Congress.” He warned, however, that if medical carriers spend “millions of dollars fighting to preserve the status quo, you may delay reform for awhile but you will increase the likelihood of a government run health system with no role for the private sector.”

In urging the insurance industry to become a part of fashioning a solution, Senator Wyden noted that in a market in which 20 percent of Americans are uninsured, carriers need to be good avoiding risk. As Senator Wyden put it, “If you don’t excel at shedding risk, you are going to enroll too many people who need too much care.  Enrolling too many people who need too much care means that your costs are going to go through the roof.  When your costs soar this way, the healthy people that you do business with are going to start looking for another insurer whose costs aren’t going through the stratosphere.  In other words they’re going to look for another insurer who does a better job of shedding risk.”

This, according to Senator Wyden, is part of the reason the current health care system is broken. Another reason is that health care in the United States is tied to the employer/employee relationship, which the Senator noted hasn’t changed much since 1948. “But economic challenges for business and workers today are very different then they were in 1948,” he noted.  “Sixty years ago employers weren’t operating in a global marketplace and employees who went to work at twenty stuck around long enough to get a gold watch and a steak dinner for retirement.  Employers need cost-containment and workers need quality health care within a system that is portable – where they can truly take their insurance from job to job.”

As an alternative, Senator Wyden suggested carriers consider a new approach in which “everyone who’s not in the military or on Medicare, has a basic private health insurance policy. Private insurance companies are on the same footing – each must take all comers. Competition would be based on price, benefit and quality.”

This is the underlying approach established by the Healthy Americans Act. In asking his audience to consider supporting the legislation, he cited six reasons why health plans would benefit from this alternative system:

  1. Bringing the 47 million uninsured into the system would greatly expand the private insurance market.
  2. There would be “no competitive disadvantage for carriers doing the right thing” and, with a risk sharing mechanism as part of the package, there would be no need to specialize in risk avoidance.
  3. The legislation supports increased information and transparency in the health marketplace.
  4. By focusing on wellness and preventive programs, carriers would be selling a product people want more of.
  5. Carriers “wouldn’t be the political football any longer.”
  6. More attention could be given to cost containment issues such as reducing needless medical errors.

He concluded his speech with a plea to carriers to be a part of the solution. “I want to ask you to become a part of the Senate’s bipartisan effort to fix American health care. Both Democrats and Republicans in the Senate want to work with you to get health care right in 2009.”

My take on all this is that the stars may be aligning for a health care reform effort that is more consultative than adversarial. Senator Barack Obama has certainly spoken of the need to have everyone, including carriers at the table. Senator Hillary Clinton has also spoken of leading a more open process than she did during her husband’s Administration. Significantly, Senator John Edwards, who promised to exclude the health insurance industry from participating in the health care reform debate, is out of the race.

I also think a move away from employer-provided coverage is likely to be a strong current in future health care reform discussions. Senator John McCain favors this approach as does the bi-partisan coalition of Senators backing the Healthy Americans Act. The business community would love to be relieved of the burden of shouldering the nation’s health care system. In speeches I began giving in 2006 I predicted that health care coverage might follow the path of pensions. Instead of companies running pension plans they moved to simply administering — and contributing to — their employee’s individual retirement plans. Similarly, employers could administer — and contribute to — employee’s individual health plans. Even though the Democratic presidential candidates still embrace an employer-centric system, the support fora more individual-centric model is gaining momentum..

For health plans this could be good news. They would remain a core part of the nation’s health care system. While the nature of their competition would change, it would still likely be a vibrant, primarily private, market.

The role of health insurance agents could change far more dramatically. If consumers are pushed into exchanges, connectors or purchasing pools, the system administrators might assume they can play the role of agents. It will be important for agents to make sure Americans continue to have access to independent advocates and consultants — in other words, to professional insurance agents. That won’t be easy. Many lawmakers — and even more of their staffs — have never worked with an agent and don’t understand the value we bring to the system.

Senator Wyden and others, however, have expressed a willingness to listen to others. That’s an opportunity agents need to seize. Fortunately agents have a compelling story to tell. 

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.

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.

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.  

Clinton and Obama on Health Care Reform: 95% the Same

Health care reform was one of the few issues on which Senators Hillary Clinton and Barack Obama tried to differentiate themselves during their debate tonight. They acknowledged substantial similarities in their plans. Senator Obama went so far as to describe them as being “95 percent” the same. Both candidates call for the government to offer consumers an alternative to the private market, for example.

When compared to the health care reform packages offered by the Republican candidates  (which rely more on market reforms and avoids extensive government intervention) the Democratic Senators’ proposals are virtually indistinguishable. But campaigns are about choices, so they emphasized the five percent.

Senator Clinton’s proposal seeks to provide universal coverage by requiring health plans to accept all applicants and all residents to buy coverage. Senator Obama focuses on reducing the cost of health care coverage. As I’ve written before, this tension between access and affordability mirrors California’s recent health care reform debate.

The candidates described their differences in stark terms, as a seemingly irreconcilable chasm between them. In reality, while differing in emphasis, these two approaches are not really either-or propositions. They’re complimentary. Don’t take my word for it — ask my son.

He turned 13 a few weeks ago. Health care reform is not high on his list of interests. However, he’s recently gotten interested in the primary so he joined me tonight to watch the debate. As Senators Clinton and Obama went back and forth on their reform packages, he asked me what the argument was about. Thanks to the miracle of DVRs I was able to pause the debate and explain. We resumed watching and, after another couple minutes of the candidate’s throwing health care statistics around he grabs the remote, presses pause and exclaims, “This is so stupid. First you make it affordable and then you make sure everyone buys it.”

So, now that we’ve got that resolved, I’m going to have him start work on creating the Democratic party’s position on immigration. 

Not That Obama Needs My Advice

Senator Barack Obama got hammered by Senator Hillary Clinton and former Senator John Edwards on his health care reform proposal at their debate earlier this week in South Carolina. Senator Obama’s focus is on making coverage affordable; Senators Clinton and Edwards emphasize universal coverage. If he continues to let his opponents define the debate this way they win and he loses.

For those who might find it interesting, I discuss how what happened in California provides a way for Senator Obama to reframe the Democratic debate on health care reform over at the political blog.

Democrats Debate Access versus Affordability in South Carolina

Health care reform was a hot topic during the presidential candidate’s debate in South Carolina on Tuesday. Senator Hillary Clinton and former Senator John Edwards claimed universal coverage was the most important priority while Senator Barack Obama put affordability at the top of his list. This dichotomy mirrors the debate California experienced with Governor Arnold Schwarzenegger insisting on coverage for all and the legislature’s Democratic leadership questioning the fairness of requiring individuals to buy coverage they couldn’t afford.

I’ve written more about this somewhat strange, but probably not surprising, echo of California’s health care reform debate on the political blog.

New Hampshire Votes: Thoughts on the Democratic Primary

Well, let’s see. I already handed the Comeback Crown to Senator John McCain in the previous post on the Republican New Hampshire primary vote. It seems unfair to deny Senator Hillary Clinton the same honor considering the polls and pundits showed her losing big to Senator Barack Obama there. Yet she defied the surveys and eked a victory, surprising, it seems, even herself.

A week ago, winning New Hampshire by just two percentage points — less than 7,500 votes — would have been proclaimed a disaster by most analysts. Now it’s a major victory and a tremendous shock. Of course, the shock is to those who wrote her off just five days ago.

Which shows how significantly, and inappropriately, Senator Obama’s victory in Iowa last Saturday changed the expectations of the Democratic nomination fight. Prior to those caucuses, Senator Clinton’s campaign focused on the depth of her experience and on the inevitability of her nomination. Then she finished third, losing out to Senator Obama and, barely, to former Senator John Edwards. Both Senators Obama and Edwards had campaigned as change agents. Senator Clinton’s message had failed to resonate and the inevitability of her success was seriously in doubt.

So in New Hampshire, she modified her message slightly, promoting herself as the candidate whose experience made her most capable of achieving change. The message seemed to reinforce the opinion of those who had supported her before the Iowa and may have been strengthened by New Hampshire voters’ penchant for thumbing their noses at expectations. According to the CNN exit poll, thirty four percent of the voters said they had made up their minds at least a month ago and Senator Clinton garnered 48 percent of their votes while Senator Obama received 31 percent.

What this says to me is that the Iowa bump for Senator Obama was in the eyes of the pundits, not among voters.

The New Hampshire results does seem to have accomplished three things. First, it put to rest talk of inevitability concerning any candidate.  Second, it confirmed the old cliche that the only poll that matters is the one on election day. Voter surveys as recent as yesterday projected a decisive win for Senator Obama. But it’s who shows up at the polls that matter, and the Clinton campaign got their voters out. I also think the polls may have worked against Senator Obama as New Hampshire voters seem to dislike being told what to do.

Third, the New Hampshire results have all but reduced the primary trail to a two person race, sending Senator Edwards on a downward spiral from which he is unlikely to recover while limiting Governor Bill Richardson to showcasing his Vice Presidential credentials and seeking favorite-son status from New Mexico.

Senator Edwards’ post-Iowa strategy was to convince voters — and the media — that the campaign was about change and Senator Clinton was incapable of delivering it. He then believed his more aggressive and partisan approach to transforming America would win out over the more conciliatory style of the Senator from Illinois.

It didn’t turn out that way. Senator Edwards received only 17 percent in the New Hampshire primary, less than half of what Senator Obama earned. Perhaps even more disastrous, polls show Senator Edwards to be even further behind Senators Clinton and Obama in the upcoming South Carolina primary, the only state he won in his unsuccessful presidential bid in 2004. As a southerner, if Senator Edwards can’t win there, it will be tough for him convince anyone he can win anywhere.

Senator Edward’s downfall stems, at least in my opinion, from his extremely partisan stance. He positioned himself as a fighter, but too much so. For example, after castigating insurance executives as greedy and accusing them of valuing profits over human life, Senator Edwards proclaimed, “And people say to me that as president of the United States, they want me to sit at a table and negotiate with these people? Never. It will never happen.’”

Now, contrast this with Senator Obama’s approach. In his concession speech tonight he promised supporters he would tell insurance and drug companies that “while they get a seat at the table, they don’t get to buy every chair. Not this time. Not now.” (This can be viwed about five minutes into the clip).  Senator Obama’s rejection of Senator Edward’s contention-as-usual politics was explicit, describing his supporters as a new majority “who are tired of the division and distraction that has clouded Whasington, who know we can disagree without being disagreeable.” (About four minutes into his speech).

Senator Edward promises a new agenda, but the same ugly, tired politics of division. Senator Obama promises changes in policy and in politics. Senator Obama finished a close second. Senator Edwards finished a distant third and, while he retains enough support and money to to continue to slog ahead, at least until February 5th when the bulk of delegates will be selected, he’s likely to be increasingly marginalized over the next four weeks.

Meanwhile, attention on the Democratic side turns to the Nevada Caucuses and the South Carolina primary (Michigan will hold a primary on January 15th, but neither Senators Obama’s or Edwards’ name is on the ballot). Senator Clinton and Obama will be seeking momentum prior to Super Duper Tuesday when California and 21 other states caucus or vote. Which means by February 6th one of the two may have emerged as unbeatable.

Which one? The odds are, marginally, favoring Senator Clinton. According to the CNN exit poll, she out-polled Senator Obama among Democratic voters 45 percent to 33 percent. It was independent voters participating in the Democratic primary that kept the Illinois Senator close with 41 percent of them supporting Senator Obama and 30 percent voting for Senator Clinton (in New Hampshire, independents can choose to cast either a Democratic or Republican ballot) .

However, not all states allow non-Democrats to vote in their primaries. Of those that do, independents comprise less of the electorate than in New Hampshire where they represent about 45 percent of all voters.

Before proclaiming Senator Clinton as the inevitable winner, however, keep in mind that in California voters registered as Decline to State  — about 19 percent of the electorate — can cast a Democratic ballot (but not a Republican one). Senator Obama’s broader appeal should serve him well here. And on February 5th, California is the biggest prize of all.