Close Votes in Reader Presidential Survey Results

The polls are open in New Hampshire, but they’ve closed on the first Alan Katz Health Care Reform Blog Unscientific Presidential Survey (the AKHCRBUPS, for short). And while we won’t know who won in the Granite state for awhile, we can now report on the winners, and losers, among this blog’s readers.

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The survey asked participants to list their second and third choice. Weighting the results (first place = 3, second place =2 and third place =1), however, doesn’t change the order of the finish, although Governor Romney does move closer to the pack as does former Senator Fred Thomas. 

The comments provided by respondents showed some Republicans displeased with their choices this election cycle. As one Republican put it, “It just might be the first time I won’t go to the polls during the primary season.”

Republicans were asked whether they “would be willing to support a Democratic candidate in the general election” and, if so, which one. A majority said no. But of those who said yes, Senator Barack Obama was their top choice, followed by former Senator John Edwards.

Democrats: Senator Hillary Clinton would be the Comeback Kid of 2008 if New Hampshire follows the AKHCRBUPS results. She tied Senator Obama for the top spot as the first choice among Democrats. Yep, tied. (They were right, every vote does count!) Senator Edwards was a distant third.

When second and third choice votes are taken into account, Senator Obama squeaks out a win over Senator Clinton. Senator Edwards and Governor Bill Richardson makes strong moves, however, with Senator Edwards coming in just ahead of the Governor. Governor Richardson seems to impress more people than are voting for him. One supporter of Senator Clinton said, “I think Richardson is being overlooked. His … national experience would be a BIG help should he be elected.” Is this the start of a Clinton/Richardson boomlet? (Probably not, but I though it was interesting.)

Good news for the GOP: When asked if, and who, Democrats would support among the Republicans, the majority said yes. Of these, Senator McCain edges out Mayor Giuliani followed, at a distance, by Representative Ron Paul.

Independents: Those who identified with neither major party got to select their preferences among all the GOP and Democratic candidates. Senator Obama was the clear winner here.

The Issues: When asked what “the two most important issues you will consider in determining which candidate to support for president,” survey participants cited the Economy as their most important issue, followed by Health Care Reform and Terrorism/National Security and then Tax Policy. Iraq was on the list, but not as high as in national polls, not suurprising given the subject matter of this blog. When second choices taken into account, the standings don’t change, but the Economy moves even further ahead while Iraq gets closer to the pack. Yet, the comments would indicate that all of these issues matter. As one respondent put it, “So which one do you pick? Holy cow!! Most all of them are crucial.”

My thanks to all of you who participated n this survey. We’ll do at least one more as the vote in California approaches.  These polls may not be scientific, but they’re fun!

Iowa Speaks!

The voters of Iowa have spoken. What they have to say may not mean much to you, but they certainly mattered to the candidates who spent months and millions trying to persuade voters not only to support them, but to brave the cold and stand around for hours in dozens of town hall like caucus meetings.

For Senator Barack Obama and former Governor Mike Huckabee it was a good day. Coming in first, by definition, is a good thing.

The key message for Democrats is that their constituency wants change. For Senator John Edwards it had to be frustrating to position yourself as the fighter for change and then to watch Senator Obama claim the change crown. But that’s what happened according to the CNN entrance survey of participants in the Democratic caucuses, 51 percent of those who stated the quality they were most looking for in a candidate was the ability to bring about change voted for Senator Obama. My guess is that Senator Edward’s extreme rhetoric worked against him and for Senator Obama.

Many voters are tired of the attack politics that is business as usual in Washington. It’s one of the reasons Congress is held in even lower esteem than President George W. Bush. House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid promised to change the tenor of the debate in Washington. They failed.

I believe most Americans want leaders who will build solutions, not tear down opponents. Seeking the mantle of Change Agent in Chief while promising to make Washington even more partisan and vicious, as Senator Edwards did, is counterproductive — at best. All he did was emphasize how much of a change the more open and inclusive style of Senator Obama would be. No wonder Senator Edwards earned only 20 percent of the vote from those whose top concern was bringing about change.

Senator Hillary Clinton had a rough night, too. Now she has to pivot from a campaign based on the inevitability of her nomination to demonstrating that she has the experience to implement the change that Senator Obama promises. Not an easy sell, but her campaign is very capable. It’s far too early to count her out.

By the way, expect both Senators Clinton and Edwards to claim second place. According to CNN, when the dust settles, Senator Edwards will have gotten a few more votes, but Senator Clinton will get 15 delegates to his 14 — compared to Senator Obama’s 16.

When asked by CNN for their top issue, health care was cited by 27 percent of those attending the Democratic caucuses, behind the war in Iraq and the economy (each mentioned by 35 percent of the voters).  Of those citing health care as their top issue, 34 percent said they were voting for Senator Obama, 30 percent for Senator Clinton and 27 percent for Senator Edwards. These numbers are so close it’s unlikely to have made much difference in the outcome. These results also reflect the narrow differences in the health care reform plans offered by the three front runners.

The CNN survey of Republican caucus goers indicate a different dynamic was at work there. First, the candidate leading in national polls, former New York mayor Rudy Giuliani didn’t campaign in Iowa. This left the field to former Governors Mitt Romney and Mike Huckabee with former Senator Fred Thompson and Senator John McCain fighting it out for a relatively distant third place finish (and it looks like Senator Thompson won the consolation prize by a hair).

The candidates views on God seemed to be the big issue for those showing up at the GOP caucuses. According to the CNN’s entrance poll,  77 percent of those attending the Republican caucus stated that the religious belief of the candidates mattered a great deal (36 percent) or somewhat (31 percent) in their decision. Only 15 percent of Republican caucus participants said the candidate’s religion didn’t matter at all. Of those who said it mattered a great deal, 56 percent said they’d be supporting Governor Huckabee. Only 11 percent said they’d be supporting Governor Romney — the same percentage that professed support for Senators McCain and Thompson.

When it came to specific issues, the top issue for 33 percent of the Republicans was illegal immigration, followed by the economy (26 percent), terrorism (21 percent) and the war in Iraq (17 percent). Health care reform didn’t make the list. A plurality of the voters citing each of these four issues as the most important to them said they’d be supporting Governor Huckabee.

What to make of the Iowa results?

  1. The expectation for Governor Huckabee and Senator Obama going into New Hampshire’s January 8th primary have gone up considerably. And it’s always a bad thing when a candidate fails to meet expectations.
  2. Coming in first in Iowa will give their war chests a nearly immediate infusion of cash (actually, credit card and Paypal donations). The Internet enables candidates to harvest contributions at speeds unfathomable in prior elections. More money will make it a bit easier for them to meet expectations. But as Governor Huckabee demonstrated to Govenor Romney, money doesn’t always translate into votes.
  3. Iowa will become yesterday’s news as soon as the New Hampshire polls close. Whatever happens there will serve as the context for the next news cycle.
  4. Perhaps most meaningful to regular readers of this blog, and as predicted here earlier, health care reform is unlikely to be a decisive factor in the primaries.

Roughly 340,000 residents of Iowa have now shaped the 2008 presidential election (that’s roughly the size of the city of Santa Ana). Now you can, too, by participating in the Alan Katz Health Care Reform Blog Unscientific Presidential Survey #1. I hope you’ll take a couple of minutes and participate. 

Health Care Reform and Iowa

With Iowans going to caucus today it’s tempting to write about how this marks the beginning of journey toward national health care reform. Unfortunately, that’s not the case. The impact of Iowa on the health care reform debate will be minimal. To be sure, there will be exit polls parsing the issues that matter to voters (health care will be high on the list). In reality, however, the positions of the candidates within each party are too similar to be sway many voters one way or the other.

On the Democratic side, the health care reform plans outlined by Senators Barack Obama and Hillary Clinton, former-Senator John Edwards, and Governor Bill Richardson are fairly similar. They all seek to reduce the uninsured through expansion of public programs. They all have cost containment provisions. The only differences are that Senator Clinton and Senator Edwards would require all consumers to obtain coverage. Senator Obama focuses more on affordability issues and Governor Richardson’s proposal avoids the creation of new bureaucracies.

On the Republican side Senator John McCain, former-Governors Mitt Romney and Mike Huckabee, and former-Mayor Rudolph Giuliani all seek to increase the number of Americans with medical coverage through tax incentives and fewer restraints on the private sector. Even Governor Romney has backed away from the heavy government role he championed in Massachusetts.

Once the general election is engaged the differences between Democrats and Republicans on health care will move front and center. That’s then. For now, even though voters are concerned about the issue, it won’t greatly impact the results coming out of Iowa.

There will be one interesting dynamic to watch, however. In Iowa, independents can choose to attend the caucus of either party. If exit polls show unaffiliated voters made their choice of caucus because of a candidate’s stand on health care reform it would provide important insight on which party’s approach is resonating with swing voters. 

That today’s caucuses in Iowa are unlikely to provide much insight into voters thinking about health care reform doesn’t make them any less interesting. They kick off the most unusual presidential election in generations. For the first time since 1928 no sitting president or vice president is on the ballot. Then there’s the sheer number of possible “firsts” we may witness. Senator Clinton could be the first woman president? Senator Obama could be the first African American to hold the office? Governor Romney is seeking to be the first Morman elected president and Mayor Giuliani wants to be the first Italian chief executive. The list goes on, but you get the idea.

And think of the possible match-ups in November. The nominees could both be New Yorkers (Senator Clinton and Mayor Giuliani). Far more interesting would be having the Republican most willing to work with Democrats (Senator McCain) facing off against the Democratic most willing to work with Republicans (Senator Obama). Then there would be the most ironic match-up: Governor Romney versus Senator Edwards — two wealthy, out-of-office white guys with perfect haircuts.

Iowa matters — just not so much concerning health care reform. Regardless of the match-up the next 11 months will be exciting. OK, not if we get stuck with Romney versus Edwards, but let’s hope it doesn’t come to that.

John Edwards’ Dangerous Rhetoric

Former Senator John Edwards talks often about two America’s: “The America of the privileged and the wealthy, and the America of those who live from paycheck to paycheck.” His populist message resonates well within the Democratic party and it has kept him among the top three candidates in most every survey taken. Usually, however, he’s in third place, and that makes everything from raising money to garnering endorsements to recruiting volunteers a bit harder. That’s why the Iowa caucuses are so critical for Senator Edwards. He needs to finish at least second to claim momentum. A third place finish merely confirms he’s behind Senators Hillary Clinton and Barack Obama. Fourth place or lower and it’s back to North Carolina.

Perhaps that explains why Senator Edwards has taken his populist message to a new and dangerous extreme. Senator Edwards is seizing on the recent tragedy of a teenage girl in California to demonize health insurance carriers and their executives. Late last month, Cigna denied Nataline Sarkisyan a liver transplant on the grounds it was experimental and, consequently, not covered. Without the assurance of being paid by the carrier, Ms. Sarkisyan’s doctors would not perform the transplant. After public pressure, including pickets at their office, Cigna relented. Unfortunately, Ms. Sarkisyan died before the procedure could begin.

The story is sad and complex. It’s easy, and lazy, to simplify what happened and ignore the subtleties. Should, for example, the doctors have performed the surgery and then worried about the money? Should they have recommended a treatment that only had a 65 percent chance of keeping the patient alive for six months? The Los Angeles Times, in its extensive coverage of the case, has done a good job of presenting these nuances. Senator Edwards has not.

Senator Edwards could have used the incident to define the difficulty of creating meaningful health care reform. Because as the Sacramento Bee’s Daniel has pointed out, Medicare and Medicaid might have made the same decision as Cigna — obtaining experimental treatment is always a judgement call whether the decision is made by a private company or a governmental agency.

Instead, Senator Edwards chose to use the tragedy as political fodder, employer language that would make the Association of Demagogues proud. According to the Des Moines Register, Senator Edwards is using the incident to ostracize the insurance industry from civil society. Here’s how the Register reports Senator Edwards as describing what happened:  “The doctors pleaded, the nurses pleaded, and finally, Americans started literally picketing and walking outside their offices…. And they finally gave in, and notified the family that they’d pay for it. But then a few hours later, she died. Because it was too late.”

This over-simplified description of what happened makes all insurance executives “Untouchables” in the mind Senator Edwards. Again from the Register: “The candidate paused for a second to let this sink in. Then his voice rose in indignation. ‘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.'”

I understand politics. I was Deputy Campaign Director for Tom Bradley in 1982 and worked alongside Joe Trippi, a Senior Adviser in Senator Edward’s campaign who has a significant impact on the Senator’s strategy and message (and who is someone for whom I have great respect). I understand the pressure to create an “us” versus “them” mentality in a tight election.

But Senator Edwards has stepped over a very important line. It’s one thing to debate the role of profits in America’s health care system. It’s fine to debate whether there should be private health insurance companies. Those are legitimate issues. But defining insurance executives — or anyone else — as unworthy to be in the presence of the president of the United States and, by implication, all right thinking people, that’s not legitimate. Once insurance executives are ostracized, who is next? Which executives or interest group is unworthy? Does the list continue to grow as the campaign heats up? Does the Senator’s enemies list include anyone who disagrees with him? This is a country built on tolerance of people and ideas. In descending into inappropriate rhetoric and a Nixonian mindset, Senator Edwards shows himself to be a politician who fails to grasp this vital aspect of America.

Maybe I’m being hypersensitive. But I’ve seen the “these people” used too often in the context of bigotry and stereotyping. (In addition to political work I’ve held leadership positions in organizations like the American Jewish Congress and the Westside Fair Housing Council). So I hope Mr. Trippi is not responsible for Senator Edward’s descent into this kind of de-humanizing rhetoric. I know him to be better than that. I don’t know Senator Edwards, but I hope he returns soon to the realm of civil discourse.

Senator Edwards is desperate to do well in Iowa. If this demagoguery is any indication, however, he’s doesn’t deserve to.

Health Care Reform, Polls and Presidential Politics

Bill Robinson, a Palm Springs insurance agent and voracious researcher on health care reform issues, recently circulated a gem of an article concerning a seeming contradiction in how Americans view the health care system. The gist of the article,  posted in November by The Century Foundation and written by Maggie Mahar, is that Americans consistently denigrate the health care system while simultaneously claiming, by huge majorities, that it works just fine for them, thank you.

Comparing results from several polls, Ms. Mahar identifies this apparent discrepancy as resulting from Americans’ satisfaction with their own current health care coverage, but insecurity about how long they’ll be able to maintain it. With premiums rising, coverage contingent on sometimes precarious employment and, if I can add to Ms. Mahar’s list, politicians constantly claiming the system is broken beyond repair, widespread insecurity is not surprising.

At the same time, there are plenty of polls showing that people don’t have a lot of confidence in how Washington runs things, either. This creates an interesting quandary for presidential candidates. Most voters feel the system needs substantive changes, yet they don’t trust the government to make things better.

It’s no surprise then, that none of the major Democratic presidential candidates have called for a government-run single payer system. Instead they call for plans that expand the size and scope of public programs to varying degrees, but preserves the private system. There are differences between the plans: Senator Barack Obama focuses on affordability, Senator Hillary Clinton, former-Senator John Edwards and Governor Bill Richardson place more emphasis on universal coverage, with Governor Richardson distinguishing himself by avoiding the creation of any new bureaucracies.

What’s significant, however, is that the second most oft used phrase by the candidates is that “no one will have to give up their current insurance if they don’t want to.” (Still holding strong in first place is “The system is broken.”) The Democratic candidates, consequently, get to have it both ways, to a degree. They get to say they’re going to fix the current system with new regulations and public programs, but they’re going to preserve private sector involvement. This may play well in the general election, but it’s not likely to excite many of the more strident constituents of the Democratic party who will accept nothing less than a single-payer system (cue the California Nurses Association).

Republican candidates face a different challenge. They have an aversion to new taxes (or cutting back on existing tax cuts). And they don’t like turning private sector services over to the government. So they focus more on affordability with few, if any, new public programs. This addresses the “my coverage is fine” dynamic the polls identified, but it doesn’t face up to the demand for change. The result is the inverse of the Democrats’ dillema: the Republican candidates’ positions will get them through the primary season all right, but it’s going to look weak after the conventions.

As the Kaiser Family Foundation surveys and other polls have shown, health care is one of the most important issues voters expect presidential candidates to address. And as Ms. Mahar points out, the polls also indicate a nuanced understanding of the issue by voters. Since the candidate’s messages must be equally nuanced, their positions tend to clump together, with obvious differences between the parties. Consequently, the specifics of the candidates’ health care proposals are not likely to be decisive in garnering support, at least not early in the primary season. What will be more important than specifics is how their proposals reinforce their core messages.

Senator Edwards, for instance, needs to show that his plan will help the poor and middle class. Which is why he emphasizes universal coverage. Senator Clinton’s program needs to underscore her claim of competency and experience, which she does by highlighting the differences between this plan and the one she pushed in her husband’s administration. Senator Obama represents a break with the past, which means his opponents do him a favor by attacking his plan. And Governor Richardson brings to the campaign broad government experience at the state and federal level. His plan underscores this by redeploying and expanding existing public programs, not creating new ones.

The importance of the health care reform issue, and of the candidates plans, will change over time. For now, however, they are mirrors of the candidates’ themes.  Which, given the seeming contradictions in the polls, is no doubt the wisest political strategy.

On Drivers Licenses, National Health Care Reform and Clinton Inevitablility

It would be ironic if whether Senator Hillary Clinton leads the upcoming national health care reform debate is decided on the issue of driver licenses for illegal immigrants, but that may be what’s happening.

Here’s the (il)logic: Senator Hillary Clinton’s campaign is based, in large part, on convincing voters and contributors that her election is inevitable. (This is a page out of Governor George W. Bush’s playback back in 1999 and it worked for him). Yet in a debate last month, Senator Clinton stumbled on a question involving providing driver licenses to those in the country illegally. Her convoluted answer seemed to both support and oppose the measure — maybe.

This stumble, in turn, reminded voters, at least in Iowa, of Senator Clinton’s image as a First Lady who had trouble speaking frankly and forthrightly. Clearly some voters found this troubling. As a result, Senator Barack Obama moved up in Iowa polls. (For a list of poll results in Iowa and elsewhere, check out RealClearPolitics.com).

Losing ground in polls is not good for an inevitability strategy. Losing the first vote in the nomination process is even worse. Senator Clinton needs to win in Iowa. To regain momentum Senator Clinton’s campaign went on the offensive against Senator Obama and one of the major lines of her attack involves health care reform. (Admit it, you were wondering if I was ever going to get back to the topic of this blog). But the tact she took seems to have been counter-productive. She claims that Senator Obama’s proposal is inadequate because it doesn’t achieve universal coverage in the way she believes it should be achieved — through a mandate that all individuals obtain coverage. (The New York Times‘ coverage of the November 15th debate in Nevada captures the tone of the two Clinton-Obama tussle on health care reform).

Yet Senator Clinton’s attacks seem to have damaged her own campaign more than Senator Obama’s, perhaps by reminding voters of her “my way or the highway” approach to reform in the 1990’s. Bringing to mind her reputation for inflexibility, not to mention her greatest political and policy failure, is not a recipe for electoral success. Senator Clinton now trails Senator Obama in most Iowa polls.

This may not mean much as polls roughly 30 days prior to the Iowa caucuses sometimes fail to indicate much of anything. Four years ago, former Governor Howard Dean and former Representative Richard Gephardt were riding high in those polls; Senators John Kerry and John Edwards were in single digits. Yet it was the two Senators who wound up finishing one-two on election day.

That the Clinton campaign has let a poor answer to a debate question lead them into a fight over health care reform generates a long list of ironies. What’s interesting is that the debate between Senators Clinton and Obama is more about tenor than goals. Senator Clinton focuses on universal coverage through an individual mandate and making coverage affordable through subsidies. Senator Obama focuses on bringing down the cost of health care and health insurance, bolstered by employer mandates. (It’s interesting to note this chicken-and-egg debate over mandates and affordability is similar to what’s happening in California, as described in an earlier post).  

Whether President Hillary Clinton is as inevitable as President George W. Bush was eight years ago is yet to be determined. If it’s not to be, however, one reason will be because of the drivers license answer — and what it drove her to do on health care. And that must be driving her campaign nuts.

Clinton Unveils Her Health Plan

That was then. This is now.

Then was when, as first lady, Hillary Clinton led the charge for health care reform. Her proposal was so unwieldy,  politically naive and arrogantly promoted that it helped Republicans take over control of Congress for the first time in over 40 years and set back the cause of health care reform by over a decade.

Now is when, as presidential candidate, Senator Hillary Clinton needs to put that history behind her and talk to the future. Which is what she did in Iowa today, unveiling the 2007 version of her health care reform plan.

Her approach this time is to be less original, less ambitious and less arrogant. Instead her new plan shares much in common with several other proposals making the rounds — including those of her rivals for the Democratic presidential nomination. This isn’t a bad thing; quite the contrary. It not only lends her plan credibility, but it provides political cover when it comes under attack.

So, for example, she shares with Governor Bill Richardson the concept that if people are satisfied with their existing coverage, they can keep it. She borrows from both Governor Richardson and Senator Barack Obama the idea of using refundable tax credits to help lower income Americans pay for their coverage. And, like Governor Richardson and former-Senator John Edwards she incorporates the idea of a requirement that all Americans obtain health care coverage and expanding MediCare eligibility.

Like many health care reform proposals — at least Democratic reform proposals — Senator Clinton would require insurers to accept all applicants without regard to their risk profile. As previously noted, she wisely balances this with a requirement that all Americans obtain coverage. What’s unclear is how she would enforce this requirement. Poor compliance by consumers would lead to the burden Senator Clinton’s state of New York bears: average insurance premiums roughly 350 percent higher than those in California.

Senator Clinton makes a major point out of avoiding the creation of new bureaucracies (another approach she shares with Governor Richardson). However, there’s something a bit disingenuous about this claim. True, instead of creating a new government health care program she would open up the Federal Employee Health Benefit Program to all Americans. However, the expansion required of the FEHBP to manage such growth would be the actuarial equivalent of creating a new bureaucracy. But with the added downside of probably disrupting the agency’s current mission.

As with all the health care reform plans put forward by presidential candidates, Senator Clinton’s proposal is more a window into her thinking than a blue print for reform. The new president will need to work with Congress to fashion a detailed reform structure. There will be plenty of debate and shaping of ideas in that process. The outcome may resemble what’s being described today, but then again, it may not.

Yet this glimpse into the approach of Senator Clinton is illuminating. By avoiding a single payer approach she demonstrates her willingness to take on the most liberal elements of her party. By imposing requirements on both corporations and individual she invites attacks from conservatives concerning a heavy-handed government approach to health care. In short, given the context of the health care reform debate as it exists today, Senator Clinton’s package is somewhere in the middle (ok, maybe a bit left of the middle, but close enough for government work). This positioning might be expected in the general election, but its a risky move in the primaries. However, it also demonstrates that Senator Clinton learned something then and she’s applying those lessons now.

Senator Barack Obama’s Health Care Reform Plan

Illinois Senator Barack Obama revealed his plans for achieving universal health care coverage today in Iowa. Text of Senator Obama’s Health Care Reform Speech. In the context of the Democratic presidential primary it’s a centrist approach which reveals much about his political philosophy and approach to policy making.

Senator Obama has previously pledged to sign a bill assuring universal health insurance coverage for all Americans. His preferred approach is an interesting mix of public and private offerings.  Senator Obama’s plan would enable all Americans to buy into a government run purchasing pool offering coverage similar to that provided to federal employees. Senator Obama calls for subsidies to help low and middle income families afford this coverage, although his speech didn’t provide details as to the amount of the subsidy or who would qualify.

Coverage through the pool would be provided on an individual basis, meaning it would remain in force even if the insured changed jobs. To pay for the subsidies, Senator Obama would let President George W. Bush’s tax cuts for the wealthiest Americans expire. He’d also levy a tax on “all but the smallest employers” who fail to provide eligible coverage to their workers.

Interestingly, unlike former North Carolina Senator John Edwards, Senator Obama does not seem to require individuals to purchase coverage. If his voluntary approach doesn’t succeed, he’s prepared to revisit the plan until 100 percent of the population is insured.

Unlike many Democratic proposals, Senator Obama explicitly called for assuring choice in the marketplace, “If you want more choices, you will also have the option of purchasing a number of affordable private plans that have similar benefits and standards for quality and efficiency.”

Central to Senator Obama’s health care reform plan are five initiatives aimed at constraining health care costs:

1.  Shifting some expenses for catastrophic health care expenses to the federal government.

2. Requiring all plans to cover “evidence-based, preventive care services” and the promotion of healthier lifestyles.

3. Reduce the $100 billion a year he estimates is wasted on poor quality care by requiring hospitals and providers to “collect, track, and publicly report measures of health care quality.”

4. Reducing waste and inefficiency through adoption of electronic medical records and other technologies.

5. Reforming the pharmaceutical and health insurance industries.  These reforms include stopping drug company practices which drive generic drugs out of the market and, interestingly, taking on insurance industry consolidation.  Noting there were over 400 health plan mergers in the past 10 years, Senator Obama pledged to investigate and prosecute the monopolization of the insurance industry. And where we do find places where insurance companies aren’t competitive, we will make them pay a reasonable share of their profits on the patients they should be caring for in the first place.”

Taken together, Senator Obama claims his cost cutting measures are expected to reduce average health insurance premiums by $2,500.

There’s a lot of details still needed to fully flesh out the Senator Obama health care reform plan. But today’s speech goes a long way to adding substance to the broad rhetoric of the past. Significantly, Senator Obama rejects the single payer system solution promoted by the liberal wing of the Democratic party and many unions. While he doesn’t explicitly criticize this approach, he does throw an implicit elbow there way when he promises that his approach means, “If you need to see a doctor, you will not have to wait in long lines for one. If you want more choices, you will also have the option of purchasing a number of affordable private plans that have similar benefits and standards for quality and efficiency.”

While rejecting a single payer approach will cost him some votes in the Democratic primaries, it positions him well for the general election if he gains his party’s nomination.  And by focusing the bulk of his speech on the need for cost containment, Obama demonstrates a sophistication on the health care reform issue often lacking in the political debate. Further evidence of his nuanced approach is a recognition that even insurance and drug companies deserve a seat at the table, even if “they don’t get to buy every chair.” All of this is evidence of a realism too often missing from the debate.

There’s much to be concerned about in his approach. One example: government run purchasing pools rarely perform as promised and usually create an unlevel playing field in the market. Another: Requiring carriers to sell coverage to all applicants, regardless of pre-existing medical conditions, without a mandate for individuals to buy coverage is a recipe for disaster. Just ask folks in New York and New Jersey.

But I doubt if Senator Obama expects his plan to be enacted as is. While promising to sign a universal coverage bill by the end of his first term, Obama has long taken a reasonable approach to reform: stay focused on the goal, but to be “agnostic in terms of how to achieve those values.” And that’s the way politics should work.

Hillary Clinton on Health Care Reform: Part II

“We’re going to have universal health care when I’m president — there’s no doubt about that. We’re going to get it done,” said presidential candidate Senator Hillary Clinton in Iowa on March 26th.  Whether this prediction comes true depends on a lot of things, most important among them: will she ever be the president and will she have the political clout to get meaningful reform enacted? As discussed in my last post, her track record on this isn’t so good.

What would Clinton health care reforms look like in a Hillary Clinton administration? She hasn’t yet provided a lot of details, but in the past week she’s at least begun to provide their outline.

Speaking at a Las Vegas candidates forum on March 25th, Clinton noted “fixing” health care would be an incremental process taking two terms of her presidency. “We all are going to try to start as soon as possible.  We can move quickly, but make no mistake, it’s going to be a series of steps.”

Clinton favors “guarantee issue” provisions, which requires insurers to accept all applicants regardless of their health conditions. At least that’s what she implied in Las Vegas. According to the Las Vegas Review Journal, Clinton claimed “Insurance companies make money by spending a lot of money and employing a lot of people to try to avoid insuring you ….” The Review Journal further reports her as calling for “an end to ‘insurance discrimination’ against people with pre-existing medical conditions.”

Let’s hope she’s not considering her home state of New York’s approach to guarantee issue, which is pretty much a disaster. As previously posted in this blog, the New York approach costs its citizens thousands of dollars each year. Consider: the average annual premium for a single New Yorker is $3,743 compared to $1,885 in California. For a family, the average annual premium in New York is $9,696 while a California family pays, on average, $3,972 per year. Given this, one hopes Clinton is considering a more nuanced approach to guarantee issue.

Unlike some of her challengers for the Democratic Party presidential nomination, Clinton seems to reject a single payer system. Here’s a portion of the transcript from the Iowa town hall meeting:  “I think we have to have a uniquely American solution to health care because we’re a different kind of country than anybody else.

“I think we will move toward requiring employers to participate the way Massachusetts does or the way California is considering. … And if you don’t insure your employees you’re going to have to pay some kind of per-employee amount so that everybody can be given insurance.” (Here’s the full transcript of the town hall meeting as posted by ABC News. The health care reform discussion begins on page 2 of the transcript).

While not supporting a single payer approach, Clinton does see the government as being an insurer of last resort for consumers who don’t get coverage from other sources such as their employers. And she would require individuals to buy coverage, presumably through this state program, with costs being borne by employers who don’t purchase coverage. As she notes, this mirrors the health care reform proposals enacted in Massachusetts by then Governor Mitt Romney and proposed in California by Governor Arnold Schwarzenegger.

Clinton is staking out a middle ground on health care reform. She’s going to get tough on insurance companies, but continue to rely on employer sponsored coverage. She’s supporting a government health plan for more Americans, but it won’t be completely government run. This may surprise some, and it should serve as fair warning for all. Remember: even if her presidential bid fails, Senator Clinton will be a powerful voice in the U.S. Senate on any health care reforms the new president has to offer.

Hillary Clinton on Health Care Reform: Part I

The botched attempt to pass comprehensive health care reform remains one of the seminal events of the Clinton Administration. It was the first time a First Lady was given responsibility for passage of such an immense public policy undertaking. Hillary Clinton undertook the responsibility with zeal, deploying a massive task force to thoroughly examine the issues and deliver a solution to the American people.

What they came up with went down in flames.

In part, this stems from the political deafness displayed by now Senator Hillary Clinton and members of her task force. There was the brilliant way they demeaned and ignored members of Congress, the rightousness in which they cloaked their arguments and the arrogance. Oh, the arrogance.

In one memorable instance for insurance agents, Hillary Clinton told Lori Proctor, a broker from Ohio, that there being no role in her plan for agents was OK, because, “… someone as bright as you could find something else to do.” An arrogant response to a legitimate question, made more foolish by making it in front of a Wall Street Journal reporter.

My favorite example of the Clinton Task Force arrogance came from Walter Zelman, formerly a deputy California Insurance Commission under (now Lieutenant Governor) John Garamendi. He explain that when Garamendi tried to remake California’s health care system it required a document of only a couple dozen pages. Now, as a member of the the Clinton Administration, he was pleased they had hundreds of pages worth of reform because that’s what it took to cover all the possible consequences of the Clinton plan. The audacity of believing a group of people could impact one-fifth of the nation’s economy and not come afoul of the law of unintended consequences, struck me as monumental folly — and unmatched arrogance.

I led the National Association of Health Underwriters’ legislative efforts during the Clinton health care debate. At one point I had the priviledge of testifying before four Congressional sub-committees in a single week. What the Clinton forces did manage to do is raise health care reform to the dominate political issue of its time. What they failed to do was accomplish anything, a squandering of an opportunity that impacts the country — and the health care reform debate — to this day.

So now Hillary Clinton is running for president. What would be in store for the country if she were to win? That’s the topic of my next post.