Re: Politics - Health Care - US

[Guest guest]

I have been following this listserve for the last few months. Finally gave notice at my HMO where I have been for 12 years that I will be leaving in April to start an IMP. This listserve has been a tremendous inspiration. Everytime I feel like I am making a mistake, I remind myself how this group if full of physicians who are happy with this same decision that I am now making. But then maybe the unhappy ones are not on this listserve (joke).

Prior to practicing in Los Angeles, I use to be an FP in Toronto, Canada. So I have to comment that is it not reasonable to think that Canada can supply Americans with their drugs. Firstly, with the Canadian dollar at par, their drugs are not that cheap. Secondly, if I remember this correctly, Canada consumes 1% of the Rx drugs in the world whereas America consumes 50% of the Rx drugs. Canada's small population, can't save America's disfunctional health care system.

My greatest disappointment in our health care system is how private insurance has us doctors by the noose. I feel like we are their puppet's. How this evolved among a group of people who are naturally independant and trained to be leaders is beyond me. It's a sad situation. How did the FP here end up giving up their freedom? Even though Canada's health care system has a top down system, most doctors are like IMP. So becoming an IMP is like going back to my roots.

I am not quite sure how all this insurance stuff works so I am going to take a short billing course. I am leaning toward cash up front and help pt bill their insurance so pt can be paid directly by their insurer. I don't want to be a slave to these insurance companies and all their rules, telling me how I have to do this or that. Maybe I will starve but looks like my rates will be be lower than the local Minute Clinic.

I have a friend who is a successful business owner who objects to government mandating businesses to buy health insurance because its not right that the government or anyone legislate that he buy something from another private company. Its would be a winfall for these private insurance companies who are not our friends.

If people are forced to buy something, then it should be from a non profit of some sort. What do you all think?

On 1/10/08, Locke's in Colorado <lockek@...

> wrote:

http://www.memag.com/memag/Medical+Economics/Election-2008-Candidates-sound-off-on-healthcare/ArticleStandard/Article/detail/479378?contextCategoryId=8485

This was out in december, so Huckabee didn't make the cut for the table.

Locke, MD

Election 2008: Candidates sound off on healthcare

The major parties' leading presidential contenders would take the country in very different directions.

Dec 21, 2007

By:Wayne J. Guglielmo

Medical Economics

To prepare for this article, Senior Editor Wayne J. Guglielmo reviewed the campaign materials of each of the candidates whose positions are detailed below.

Few issues tap as deeply into the philosophical wellsprings of the two major parties as healthcare does.

The partisan battle this fall over SCHIP—the State Children's Health Insurance Program—is a case in point, despite defections to the other side by typically loyal Republicans. (In mid-October, the House upheld a presidential veto.) The philosophical divide is also evident in the presidential race, although even here there have been a few unexpected turns.

The candidates plans at a glanceIn various ways, the leading Democrats—Hillary Clinton (D-NY), Barack Obama (D-IL), and —rely partially on government to guarantee a certain level of healthcare coverage to all Americans. For a party that's fond of using government muscle to solve big, hard social problems, this is pretty standard fare.

And yet with the exception of Ohio Rep. Dennis Kucinich, none of the Democratic candidates, leading or trailing, has tacked too far to the left in the primary campaigns in order to appeal to the party's traditionally liberal base. Sen. Clinton, for instance, does her best not to rock the boat of the millions of middle-income people who have employer-based or individual insurance, and like it.

In contrast, the leading Republican candidates—Rudy Giuliani, Fred , Mitt Romney, and McCain (R-AZ)— have cleaved fairly closely to the party's conservative base. Whether that will change in the general election is unclear. (At press time, former Arkansas Gov. Mike Huckabee was rising in the GOP rankings.)

What is clear is that, unlike the Democrats, the Republicans want to minimize government's role, principally through a series of taxed-based incentives that would encourage Americans to purchase health insurance on the private market. Even former Gov. Romney has thus far tacked further to the right, declaring that his own Massachusetts health plan, a classic Republican-Democratic compromise, is not right for every state.

How the leading candidates compare

The leading Democrats seem eager this time around not to repeat the mistakes of the early 1990s, when the first Clinton health plan, spearheaded by then First Lady Hillary Clinton, was rolled out. There's greater emphasis now on choice, shared responsibility, and affordability. And though each of the leading candidates still wants universal coverage, the mechanisms by which they would reach that ambitious goal, many observers point out, have changed significantly.

Not significantly enough, say the Republicans. Former Gov. Romney's response to Hillary Clinton's plan typifies their reaction: " It's government insurance, not private insurance. . . . It's a European-style socialized medicine plan—that's where it leads—and that's the wrong direction for America. "

Universal coverage. Each of the leading Democratic candidates has adopted the individual mandate, to varying degrees. Both Clinton and require all Americans to obtain health coverage, but offers special exemptions " in cases of extreme financial hardship or religious beliefs. " And Obama's mandate applies only to children.

Under Clinton, people would either retain their existing coverage or select from one of two options: a broad array of private plans under the aegis of the Federal Employees Health Benefits Program (FEHBP) or a Medicare-like public plan. Under , people not enrolled in Medicare, Medicaid, SCHIP, or an employer-based program would be eligible to buy coverage through a series of regional Health Care Markets, which would offer a choice between private and public coverage.

Under Obama's plan, children would be eligible to remain in their parents' plans up to age 25. And children in poorer families would be covered through Medicaid or SCHIP, which he would expand. For older Americans without coverage, Obama offers a public choice or a private one very similar to Clinton's and ', overseen by a " National Health Insurance Exchange " —a sort of public watchdog. Obama would also offer subsidies in the form of income-based tax credits to eligible individuals and families.

A federal healthcare-for-all requirement holds little attraction for the leading Republican candidates. None supports it—and several actively oppose it. " We do not believe in coercion and the use of state power to mandate care, coverage, or costs, " McCain has said. To achieve more widespread coverage, front-runner Rudy Giuliani would improve and expand health savings accounts, as would Mitt Romney and Sen. McCain. For middle-income Americans without employer-based coverage, Giuliani would offer an income tax exclusion of up to $15,000. For those lower on the income scale, he proposes a health insurance credit, presumably payable in advance, which could be coupled with either an employer contribution or a public program, such as Medicaid.

Like Giuliani, Romney would reform the tax code, including granting full deductibility for qualified medical expenses. Sen. McCain would expand private coverage by offering a $2,500 tax credit ($5,000 for families) to everyone with health insurance. Former Tennessee Sen. Fred 's plan is sketchy at this point, although, like his GOP colleagues, he favors a system built around " individual consumers " and " affordable healthcare options. "

Employer mandate. Each of the leading Democrat's plans requires employers to provide coverage for employees, although, here again, details differ. goes the furthest in this direction, requiring all employers either to cover their workers or help finance their health insurance. Both Clinton and Obama exempt small businesses from this mandate, although neither candidate has spelled out the precise size limits. To encourage small employers to provide coverage or continue offering it, Clinton's plan includes a tax credit.

The leading Republicans favor a free-market approach, and are, therefore, as opposed to the employer mandate as they are to a requirement for individual coverage. As a group, their strategy is to shift as much money as possible from the employer-based group market to the individual market. The primary mechanism for doing this—as noted above—is through targeted changes in the tax code.

Medicaid and SCHIP. All leading Democrats would expand or strengthen these two programs. , the only candidate to offer specifics, promises to provide enough federal funding to the states to permit them to cover all children and parents under 250 percent of the federal poverty line, or about $50,000 for a family of four.

As a group, the leading Republican candidates take a different tact. Rather than expand these public programs, their approach is to give states the flexibility to enact what Giuliani refers to as innovative changes. Romney would like to " block grant " federal Medicaid funds and remove " burdensome administrative requirements. " McCain would like states to use their Medicaid and SCHIP funds to help pay for private, rather than public, insurance.

Disease prevention and chronic care. All of the leading Democrats include measures to address these two areas, both as something worthy in and of themselves and as part of their larger cost-saving strategies. Clinton, for example, thinks billions could be saved by, among other things, offering proven preventive services to all Americans. Any private plan doing business with the government would be required to offer these services ( and Obama establish a similar requirement.) She'd also encourage, as would , federally funded plans to establish continuing care innovations—including " medical homes. "

The Republican candidates also weigh in on these two areas, albeit less specifically than their Democratic counterparts. Giuliani and think health insurance should be redefined to cover wellness and not just sickness. Giuliani would promote wellness programs and tie a state's Medicaid payments to how well it handled preventive care and childhood obesity. By encouraging personal responsibility, McCain would try to prevent " expensive " chronic diseases. He would also focus more attention on disease management rather than complex procedures by changing the way Medicare pays providers.

Evidence-based medicine. All of the leading Democratic candidates would establish some kind of organization to collect and analyze best practices. suggests an agency within the Institute of Medicine, Clinton a federal-private " Best Practices Institute, " and Obama an " independent, " presumably nongovernmental institute.

Two of the leading Republican candidates have addressed these issues directly, though generally. McCain wants to develop " national standards for measuring and recording treatments and outcomes, " while disallowing Medicare payments for " preventable medical errors. " wants to encourage " the widespread use of best practices. "

Information technology. In the digital age, no forward-thinking candidate can risk seeming indifferent to the hoped-for cost-savings and quality-improvement benefits of EHRs, electronic registries, hand-held devices, and the like. Among the Democrats, Obama would invest $10 billion a year over the next five years—and Clinton $3 billion a year—to beef up the nation's IT infrastructure, while preserving patient privacy rights. Clinton also promises to give doctors financial incentives to adopt health IT. Though less specific about the dollars he'd invest, seems equally committed to reducing the paper chase, while enforcing patient privacy protections.

All of the leading Republicans touch on IT expansion as well. Giuliani, for example, calls for public-private partnerships to set the right standards, " without overbearing regulation. " McCain wants to promote the " rapid deployment of 21st century information systems. "

Drug costs. All of the leading Democratic candidates would permit Medicare to negotiate lower drug prices. Both Clinton and Obama want to remove barriers to generic competition, and and Obama would open up drug reimportation. (While limits this measure to Canada, Obama talks about including " developed countries " generally, under certain conditions.) Clinton would also " create a pathway to biogeneric competition " and more closely monitor the financial relationships between drugmakers and physicians.

McCain is the only leading Republican candidate to hold out the possibility of controlling costs through the " safe reimportation of drugs " and the " faster introduction " of generics. For his part, Giuliani wants to reduce costs and save lives by streamlining the FDA approval process.

Medical malpractice. Of the three Democratic candidates, Clinton is the only one whose plan doesn't touch on the issue directly. She has previously supported liability protections for physicians who disclose errors and negotiate a fair compensation with patients, though. Besides a voluntary reporting system, , a former trial lawyer, supports mandatory sanctions against attorneys who file frivolous lawsuits, as well as measures to beef up state medical boards. Obama talks about preventing medical liability insurers from charging doctors exorbitant rates, among other things.

Historically, medical malpractice has been a big issue for Republicans. Giuliani talks generally about ending frivolous lawsuits and excessive damage awards, without limiting compensation for real economic loss. Romney and McCain take more specific stands. Romney promises to push for a federal cap on noneconomic and punitive awards, and McCain would like to eliminate " frivolous lawsuits for doctors that follow clinical guidelines and adhere to patient safety protocols. "

Overall costs. Rather than identifying what their plans would cost, the leading Democratic candidates focus on what they claim their plans would save. Among other things, Clinton would phase out " overpayments " to Medicare Advantage plans ($10 billion), modernize the health system through IT adoption and other improvements ($35 billion), modify the Bush tax cuts ($52 billion), and cap the medical benefits income tax exclusion for households making more than $250,000 ($2 billion). In all, she asserts, she can save—and then reinvest back into the system—$110 billion. and Obama make only somewhat less optimistic projections.

The Republicans talk about making the healthcare system more efficient through IT development and the like. But they place most of their chips on the putative cost-saving benefits of consumer-directed healthcare. McCain makes the case this way: " American families know quality when they see it, so their dollars should be in their hands. " When it is, they're " less likely to choose the most expensive and often unnecessary options. " Families should be able to purchase healthcare coverage nationwide, across state lines, both to maximize consumer choice and heighten competition for their business, he says.

For many observers, neither the Democratic nor the Republican cost-savings proposals are up to the task. " Neither side has made any of the tougher efforts to try to restrain costs and spending, " says Blendon, professor of health policy and political analysis at Harvard. The candidates have soft-pedaled the cost issue, Blendon says, not only because it threatens interest groups—physicians, hospitals, drugmakers, insurers—but also because it threatens middle-income voters with the specter of limiting or rationing care.

That specter could show up as part of future legislation, of course, depending on who's in power. Right now, though, the candidates are more concerned with laying out their visions—which, whatever else they have going for them, will give voters a clear choice of direction.

From: [mailto:

] On Behalf Of mkcl6@...Sent: Thursday, January 10, 2008 4:34 AM To: Subject: Re: France is healthcare leader, US comes dead last: study --> was RE: [Pract...

I heard Mike Huckabee speak last fall, I think there are several things I don't like about him, but he has his mind around health and prevention and REALLY seems to understand it. He doesn't seem to have a really well flushed out plan, but like I said, he had a deep and seemingly accurate understanding about health and prevention. Doesn't mean I'll vote for him, but he is still on the table.

Did anyone else review the table of the candidates views in Medical Economics? (I think that's where it was.) Kris

Start the year off right.

Easy ways to stay in shape in the new year.

[Guest guest]

I started Med school in 1971 and got out of residency in 1978.

I was in the National Health Service Corps until 1983 when I started

pvt. practice. At that time there were no basically no HMOs except

for Kaiser. You could see any patient with insurance and give them

a " Superbill " which they were responsible for sending to their

insurance company for reimbursement. You could also have the patient

sign over their benefit and you could bill insurance yourself if you

wanted, but most doctors did not choose to do that. HMO rules were

basically a product of the Nixon administration in the early 1970s

which was when the rules were passed, but they did not take off and

were shunned by most private doctors. My take on when things started

changing, in this area at least, was when the spector of nationalized

health care seemed likely to happen when Clinton was elected and it

looked like Hillary Clinton would push through a National health

insurance plan. A lot of doctors were so afraid of the idea of

nationalized health care, that they felt like signing on with HMOs

would be a way of combating it. The other factor was that the older

indemnity insurance plans had premiums that were escalating in 40%

increments every 6-9 months. I used to be insured under the county

medical society but had to drop it after several 40% premium jumps

within a short timein the early 1980s. Patients and employers

couldn't buy regular indemnity insurance any longer, so they started

going to HMO's and PPOs. In areas where there were a lot of doctors

competing with each other, like S. Calif. they started having to sign

on with HMOs and PPOs in order to have any patients. It took a lot

longer for that to happen up here in the San Joaquin Valley but

eventually it happend up here also. However, we still don't have

Medicare HMOs up here because they tried it and they failed, because

the insurance co's could not make any money on Medicare HMO's in the

San Joaquin Valley due to the lower capitation rate they pay in this

area, and they pulled out after a couple of years. We still have only

traditional Medicare here. I was signed up for Medicare HMO for a

while when they had it in our area, and I would never go back to that

again if it comes back, I would rather just take whatever cash

patients I could get or retire and flip hamburgers.

Caldwell

Tulare, CA

> >

> >

> > http://www.memag.com/memag/Medical+Economics/Election-2008-

Candidates-sound-off-on-

healthcare/ArticleStandard/Article/detail/479378?

contextCategoryId=8485

> >

> > This was out in december, so Huckabee didn't make the cut for the

table.

> >

> > Locke, MD

> >

> >

> > <http://www.memag.com/> [image: Print]

Election

> > 2008: Candidates sound off on healthcare

> > The major parties' leading presidential contenders would

take the

> > country in very different directions.

> > Dec 21, 2007 By:Wayne J.

Guglielmo<http://www.memag.com/memag/author/authorInfo.jsp?id=6664>

Medical

> > Economics

> >

> > *To prepare for this article, Senior Editor Wayne J. Guglielmo

reviewed

> > the campaign materials of each of the candidates whose positions

are

> > detailed below.*

> >

> > Few issues tap as deeply into the philosophical wellsprings of

the two

> > major parties as healthcare does.

> >

> > The partisan battle this fall over SCHIP—the State Children's

Health

> > Insurance Program—is a case in point, despite defections to the

other side

> > by typically loyal Republicans. (In mid-October, the House upheld

a

> > presidential veto.) The philosophical divide is also evident in

the

> > presidential race, although even here there have been a few

unexpected

> > turns.

> >

> > <http://www.memag.com/memag/content/printContentPopup.jsp?

id=479378#>

> > The candidates plans at a glance

> > In various ways, the leading Democrats—Hillary Clinton (D-NY),

Barack

> > Obama (D-IL), and —rely partially on government to

guarantee a

> > certain level of healthcare coverage to all Americans. For a

party that's

> > fond of using government muscle to solve big, hard social

problems, this is

> > pretty standard fare.

> >

> > And yet with the exception of Ohio Rep. Dennis Kucinich, none of

the

> > Democratic candidates, leading or trailing, has tacked too far to

the left

> > in the primary campaigns in order to appeal to the party's

traditionally

> > liberal base. Sen. Clinton, for instance, does her best not to

rock the boat

> > of the millions of middle-income people who have employer-based or

> > individual insurance, and like it.

> >

> > In contrast, the leading Republican candidates—Rudy Giuliani, Fred

> > , Mitt Romney, and McCain (R-AZ)— have cleaved

fairly closely

> > to the party's conservative base. Whether that will change in the

general

> > election is unclear. (At press time, former Arkansas Gov. Mike

Huckabee was

> > rising in the GOP rankings.)

> >

> > What is clear is that, unlike the Democrats, the Republicans want

to

> > minimize government's role, principally through a series of taxed-

based

> > incentives that would encourage Americans to purchase health

insurance on

> > the private market. Even former Gov. Romney has thus far tacked

further to

> > the right, declaring that his own Massachusetts health plan, a

classic

> > Republican-Democratic compromise, is not right for every state.

> >

> > *How the leading candidates compare*

> >

> > The leading Democrats seem eager this time around *not* to repeat

the

> > mistakes of the early 1990s, when the first Clinton health plan,

spearheaded

> > by then First Lady Hillary Clinton, was rolled out. There's

greater emphasis

> > now on choice, shared responsibility, and affordability. And

though each of

> > the leading candidates still wants universal coverage, the

mechanisms by

> > which they would reach that ambitious goal, many observers point

out, have

> > changed significantly.

> >

> > Not significantly enough, say the Republicans. Former Gov.

Romney's

> > response to Hillary Clinton's plan typifies their reaction: " It's

government

> > insurance, not private insurance. . . . It's a European-style

socialized

> > medicine plan—that's where it leads—and that's the wrong

direction for

> > America. "

> >

> > *Universal coverage. *Each of the leading Democratic candidates

has

> > adopted the individual mandate, to varying degrees. Both Clinton

and

> > require *all* Americans to obtain health coverage, but

offers

> > special exemptions " in cases of extreme financial hardship or

religious

> > beliefs. " And Obama's mandate applies only to children.

> >

> > Under Clinton, people would either retain their existing coverage

or

> > select from one of two options: a broad array of private plans

under the

> > aegis of the Federal Employees Health Benefits Program (FEHBP) or

a

> > Medicare-like public plan. Under , people not enrolled in

Medicare,

> > Medicaid, SCHIP, or an employer-based program would be eligible

to buy

> > coverage through a series of regional Health Care Markets, which

would offer

> > a choice between private and public coverage.

> >

> > Under Obama's plan, children would be eligible to remain in their

parents'

> > plans up to age 25. And children in poorer families would be

covered through

> > Medicaid or SCHIP, which he would expand. For older Americans

without

> > coverage, Obama offers a public choice or a private one very

similar to

> > Clinton's and ', overseen by a " National Health Insurance

Exchange " —a

> > sort of public watchdog. Obama would also offer subsidies in the

form of

> > income-based tax credits to eligible individuals and families.

> >

> > A federal healthcare-for-all requirement holds little attraction

for the

> > leading Republican candidates. None supports it—and several

actively oppose

> > it. " We do not believe in coercion and the use of state power to

mandate

> > care, coverage, or costs, " McCain has said. To achieve more

widespread

> > coverage, front-runner Rudy Giuliani would improve and expand

health savings

> > accounts, as would Mitt Romney and Sen. McCain. For middle-income

Americans

> > *without* employer-based coverage, Giuliani would offer an income

tax

> > exclusion of up to $15,000. For those lower on the income scale,

he proposes

> > a health insurance credit, presumably payable in advance, which

could be

> > coupled with either an employer contribution or a public program,

such as

> > Medicaid.

> >

> > Like Giuliani, Romney would reform the tax code, including

granting full

> > deductibility for qualified medical expenses. Sen. McCain would

expand

> > private coverage by offering a $2,500 tax credit ($5,000 for

families) to

> > everyone with health insurance. Former Tennessee Sen. Fred

's plan

> > is sketchy at this point, although, like his GOP colleagues, he

favors a

> > system built around " individual consumers " and " affordable

healthcare

> > options. "

> >

> > *Employer mandate. *Each of the leading Democrat's plans requires

> > employers to provide coverage for employees, although, here

again, details

> > differ. goes the furthest in this direction, requiring

all employers

> > either to cover their workers or help finance their health

insurance. Both

> > Clinton and Obama exempt small businesses from this mandate,

although

> > neither candidate has spelled out the precise size limits. To

encourage

> > small employers to provide coverage or continue offering it,

Clinton's plan

> > includes a tax credit.

> >

> > The leading Republicans favor a free-market approach, and are,

therefore,

> > as opposed to the employer mandate as they are to a requirement

for

> > individual coverage. As a group, their strategy is to shift as

much money as

> > possible from the employer-based group market to the individual

market. The

> > primary mechanism for doing this—as noted above—is through

targeted changes

> > in the tax code.

> >

> > *Medicaid and SCHIP. *All leading Democrats would expand or

strengthen

> > these two programs. , the only candidate to offer

specifics, promises

> > to provide enough federal funding to the states to permit them to

cover all

> > children and parents under 250 percent of the federal poverty

line, or about

> > $50,000 for a family of four.

> >

> > As a group, the leading Republican candidates take a different

tact.

> > Rather than expand these public programs, their approach is to

give states

> > the flexibility to enact what Giuliani refers to as innovative

changes.

> > Romney would like to " block grant " federal Medicaid funds and

remove

> > " burdensome administrative requirements. " McCain would like

states to use

> > their Medicaid and SCHIP funds to help pay for private, rather

than public,

> > insurance.

> >

> > *Disease prevention and chronic care. *All of the leading

Democrats

> > include measures to address these two areas, both as something

worthy in and

> > of themselves and as part of their larger cost-saving strategies.

Clinton,

> > for example, thinks billions could be saved by, among other

things, offering

> > proven preventive services to all Americans. Any private plan

doing business

> > with the government would be required to offer these services

( and

> > Obama establish a similar requirement.) She'd also encourage, as

would

> > , federally funded plans to establish continuing care

> > innovations—including " medical homes. "

> >

> > The Republican candidates also weigh in on these two areas,

albeit less

> > specifically than their Democratic counterparts. Giuliani and

think

> > health insurance should be redefined to cover wellness and not

just

> > sickness. Giuliani would promote wellness programs and tie a

state's

> > Medicaid payments to how well it handled preventive care and

childhood

> > obesity. By encouraging personal responsibility, McCain would try

to prevent

> > " expensive " chronic diseases. He would also focus more attention

on disease

> > management rather than complex procedures by changing the way

Medicare pays

> > providers.

> >

> > *Evidence-based medicine. *All of the leading Democratic

candidates would

> > establish some kind of organization to collect and analyze best

practices.

> > suggests an agency within the Institute of Medicine,

Clinton a

> > federal-private " Best Practices Institute, " and Obama

an " independent, "

> > presumably nongovernmental institute.

> >

> > Two of the leading Republican candidates have addressed these

issues

> > directly, though generally. McCain wants to develop " national

standards for

> > measuring and recording treatments and outcomes, " while

disallowing Medicare

> > payments for " preventable medical errors. " wants to

encourage " the

> > widespread use of best practices. "

> >

> > *Information technology. *In the digital age, no forward-thinking

> > candidate can risk seeming indifferent to the hoped-for cost-

savings and

> > quality-improvement benefits of EHRs, electronic registries, hand-

held

> > devices, and the like. Among the Democrats, Obama would invest

$10 billion a

> > year over the next five years—and Clinton $3 billion a year—to

beef up the

> > nation's IT infrastructure, while preserving patient privacy

rights. Clinton

> > also promises to give doctors financial incentives to adopt

health IT.

> > Though less specific about the dollars he'd invest, seems

equally

> > committed to reducing the paper chase, while enforcing patient

privacy

> > protections.

> >

> > All of the leading Republicans touch on IT expansion as well.

Giuliani,

> > for example, calls for public-private partnerships to set the

right

> > standards, " without overbearing regulation. " McCain wants to

promote the

> > " rapid deployment of 21st century information systems. "

> >

> > *Drug costs. *All of the leading Democratic candidates would

permit

> > Medicare to negotiate lower drug prices. Both Clinton and Obama

want to

> > remove barriers to generic competition, and and Obama

would open up

> > drug reimportation. (While limits this measure to Canada,

Obama

> > talks about including " developed countries " generally, under

certain

> > conditions.) Clinton would also " create a pathway to biogeneric

competition "

> > and more closely monitor the financial relationships between

drugmakers and

> > physicians.

> >

> > McCain is the only leading Republican candidate to hold out the

> > possibility of controlling costs through the " safe reimportation

of drugs "

> > and the " faster introduction " of generics. For his part, Giuliani

wants to

> > reduce costs and save lives by streamlining the FDA approval

process.

> >

> > *Medical malpractice. *Of the three Democratic candidates,

Clinton is the

> > only one whose plan doesn't touch on the issue directly. She has

previously

> > supported liability protections for physicians who disclose

errors and

> > negotiate a fair compensation with patients, though. Besides a

voluntary

> > reporting system, , a former trial lawyer, supports

mandatory

> > sanctions against attorneys who file frivolous lawsuits, as well

as measures

> > to beef up state medical boards. Obama talks about preventing

medical

> > liability insurers from charging doctors exorbitant rates, among

other

> > things.

> >

> > Historically, medical malpractice has been a big issue for

Republicans.

> > Giuliani talks generally about ending frivolous lawsuits and

excessive

> > damage awards, without limiting compensation for real economic

loss. Romney

> > and McCain take more specific stands. Romney promises to push for

a federal

> > cap on noneconomic and punitive awards, and McCain would like to

eliminate

> > " frivolous lawsuits for doctors that follow clinical guidelines

and adhere

> > to patient safety protocols. "

> >

> > *Overall costs. *Rather than identifying what their plans would

cost, the

> > leading Democratic candidates focus on what they claim their

plans would *

> > save*. Among other things, Clinton would phase out " overpayments "

to

> > Medicare Advantage plans ($10 billion), modernize the health

system through

> > IT adoption and other improvements ($35 billion), modify the Bush

tax cuts

> > ($52 billion), and cap the medical benefits income tax exclusion

for

> > households making more than $250,000 ($2 billion). In all, she

asserts, she

> > can save—and then reinvest back into the system—$110 billion.

and

> > Obama make only somewhat less optimistic projections.

> >

> > The Republicans talk about making the healthcare system more

efficient

> > through IT development and the like. But they place most of their

chips on

> > the putative cost-saving benefits of consumer-directed

healthcare. McCain

> > makes the case this way: " American families know quality when

they see it,

> > so their dollars should be in their hands. " When it is,

they're " less likely

> > to choose the most expensive and often unnecessary options. "

Families should

> > be able to purchase healthcare coverage nationwide, across state

lines, both

> > to maximize consumer choice and heighten competition for their

business, he

> > says.

> >

> > For many observers, neither the Democratic nor the Republican

cost-savings

> > proposals are up to the task. " Neither side has made any of the

tougher

> > efforts to try to restrain costs and spending, " says

Blendon,

> > professor of health policy and political analysis at Harvard. The

candidates

> > have soft-pedaled the cost issue, Blendon says, not only because

it

> > threatens interest groups—physicians, hospitals, drugmakers,

insurers—but

> > also because it threatens middle-income voters with the specter

of limiting

> > or rationing care.

> >

> > That specter *could* show up as part of future legislation, of

course,

> > depending on who's in power. Right now, though, the candidates

are more

> > concerned with laying out their visions—which, whatever else they

have going

> > for them, will give voters a clear choice of direction.

> >

> > ------------------------------

> > *From:*

[mailto: ]

> > *On Behalf Of *mkcl6@...

> > *Sent:* Thursday, January 10, 2008 4:34 AM

> > *To:*

> > *Subject:* Re: France is healthcare

leader, US

> > comes dead last: study --> was RE: [Pract...

> >

> >

> > I heard Mike Huckabee speak last fall, I think there are several

things I

> > don't like about him, but he has his mind around health and

prevention and

> > REALLY seems to understand it. He doesn't seem to have a really

well

> > flushed out plan, but like I said, he had a deep and seemingly

accurate

> > understanding about health and prevention. Doesn't mean I'll vote

for him,

> > but he is still on the table.

> >

> > Did anyone else review the table of the candidates views in

Medical

> > Economics? (I think that's where it was.) Kris

> >

> >

> >

> > ------------------------------

> > Start the year off right. Easy ways to stay in

shape<http://body.aol.com/fitness/winter-exercise?

NCID=aolcmp00300000002489>in the new year.

> >

> >

> >

>

[Guest guest]

I don’t particularly like

the Clintons, but I don’t think you can blame for the HMO debacle.

As I remember, her plan was based to a large degree on privately owned and run

HMO type networks grouped by state or geographic region. It’s great

mistake in a Republican congress was universal coverage and central oversight

by the feds. I moved from VA to CA in 1991 to start my residency at Ventura. It was my introduction

to HMOs and such. Even then, you could see that HMOs didn’t really cut

insurance costs; that they simply transferred payments from healthcare providers

to the accountants, managers and businessocracy of the privately held insurance

companies. They were cheaper than indemnity plans, true; but the same

companies sold and set the price for both indemnity and HMO plans. It was

also the beginning of globalization and employers were looking for ways to cut

insurance costs to compete with cheaper foreign manufacturers. You can

blame that on the Clintons. As you said, as employers started offering only HMO type

plans, MDs were forced to accept them or lose patients. Some insurers

had/have 30-40% of the local “covered lives” and the only easy way

to access those patients is to participate with the HMOs. By the time I returned

to VA in 1994, HMOs very common here and continue to be. I haven’t had

any experience with Kaiser since residency, but they always seemed different

than the other HMOs as they were so totally vertically integrated from primary

care offices to tertiary care hospitals (is there such a thing as secondary

care?), and did not need to negotiate contracts with hospitals and such.

Straz

* Re: France is healthcare

leader, US

> > comes dead last: study --> was RE: [Pract...

> >

> >

> > I heard Mike Huckabee speak last fall, I think there are several

things I

> > don't like about him, but he has his mind around health and

prevention and

> > REALLY seems to understand it. He doesn't seem to have a really

well

> > flushed out plan, but like I said, he had a deep and seemingly

accurate

> > understanding about health and prevention. Doesn't mean I'll vote

for him,

> > but he is still on the table.

> >

> > Did anyone else review the table of the candidates views in

Medical

> > Economics? (I think that's where it was.) Kris

> >

> >

> >

> > ------------------------------

> > Start the year off right. Easy ways to stay in

shape<http://body.aol.com/fitness/winter-exercise?

NCID=aolcmp00300000002489>in the new year.

> >

> >

> >

>

[Guest guest]

You're right, I did not mean to bash Hillary. It was a culmination

of a lot of complex forces at work. As you say, the globalization of

the economy with the

reduction of power of the unions to negotiate their benefits, loss of

life time job security etc.

It wasn't that the HMOs could offer insurance at reduced premiums, it

was that the old indemnity plans just went out of sight. The HMOs

cost as much or more than the old plans did, and the costs continued

to escalate as well. I do think the docs at the time hoped that the

coporate bean counters of the HMOs would be more favorable to deal

with than government bean counters. So they tended to favor going the

HMO route than a National health plan. That's just

the way I remember things. But then my hippocampal volume is

shrinking!

Caldwell

Tulare, CA

> > >

> > >

> > > http://www.memag.

> <http://www.memag.com/memag/Medical+Economics/Election-2008->

> com/memag/Medical+Economics/Election-2008-

> Candidates-sound-off-on-

> healthcare/ArticleStandard/Article/detail/479378?

> contextCategoryId=8485

> > >

> > > This was out in december, so Huckabee didn't make the cut for

the

> table.

> > >

> > > Locke, MD

> > >

> > >

> > > <http://www.memag. <http://www.memag.com/> com/> [image: Print]

> Election

> > > 2008: Candidates sound off on healthcare

> > > The major parties' leading presidential contenders would

> take the

> > > country in very different directions.

> > > Dec 21, 2007 By:Wayne J.

> Guglielmo<http://www.memag.

> <http://www.memag.com/memag/author/authorInfo.jsp?id=6664>

> com/memag/author/authorInfo.jsp?id=6664>

> Medical

> > > Economics

> > >

> > > *To prepare for this article, Senior Editor Wayne J. Guglielmo

> reviewed

> > > the campaign materials of each of the candidates whose

positions

> are

> > > detailed below.*

> > >

> > > Few issues tap as deeply into the philosophical wellsprings of

> the two

> > > major parties as healthcare does.

> > >

> > > The partisan battle this fall over SCHIP-the State Children's

> Health

> > > Insurance Program-is a case in point, despite defections to the

> other side

> > > by typically loyal Republicans. (In mid-October, the House

upheld

> a

> > > presidential veto.) The philosophical divide is also evident in

> the

> > > presidential race, although even here there have been a few

> unexpected

> > > turns.

> > >

> > > <http://www.memag.

> <http://www.memag.com/memag/content/printContentPopup.jsp?>

> com/memag/content/printContentPopup.jsp?

> id=479378#>

> > > The candidates plans at a glance

> > > In various ways, the leading Democrats-Hillary Clinton (D-NY),

> Barack

> > > Obama (D-IL), and -rely partially on government to

> guarantee a

> > > certain level of healthcare coverage to all Americans. For a

> party that's

> > > fond of using government muscle to solve big, hard social

> problems, this is

> > > pretty standard fare.

> > >

> > > And yet with the exception of Ohio Rep. Dennis Kucinich, none

of

> the

> > > Democratic candidates, leading or trailing, has tacked too far

to

> the left

> > > in the primary campaigns in order to appeal to the party's

> traditionally

> > > liberal base. Sen. Clinton, for instance, does her best not to

> rock the boat

> > > of the millions of middle-income people who have employer-based

or

> > > individual insurance, and like it.

> > >

> > > In contrast, the leading Republican candidates-Rudy Giuliani,

Fred

> > > , Mitt Romney, and McCain (R-AZ)- have cleaved

> fairly closely

> > > to the party's conservative base. Whether that will change in

the

> general

> > > election is unclear. (At press time, former Arkansas Gov. Mike

> Huckabee was

> > > rising in the GOP rankings.)

> > >

> > > What is clear is that, unlike the Democrats, the Republicans

want

> to

> > > minimize government's role, principally through a series of

taxed-

> based

> > > incentives that would encourage Americans to purchase health

> insurance on

> > > the private market. Even former Gov. Romney has thus far tacked

> further to

> > > the right, declaring that his own Massachusetts health plan, a

> classic

> > > Republican-Democratic compromise, is not right for every state.

> > >

> > > *How the leading candidates compare*

> > >

> > > The leading Democrats seem eager this time around *not* to

repeat

> the

> > > mistakes of the early 1990s, when the first Clinton health

plan,

> spearheaded

> > > by then First Lady Hillary Clinton, was rolled out. There's

> greater emphasis

> > > now on choice, shared responsibility, and affordability. And

> though each of

> > > the leading candidates still wants universal coverage, the

> mechanisms by

> > > which they would reach that ambitious goal, many observers

point

> out, have

> > > changed significantly.

> > >

> > > Not significantly enough, say the Republicans. Former Gov.

> Romney's

> > > response to Hillary Clinton's plan typifies their

reaction: " It's

> government

> > > insurance, not private insurance. . . . It's a European-style

> socialized

> > > medicine plan-that's where it leads-and that's the wrong

> direction for

> > > America. "

> > >

> > > *Universal coverage. *Each of the leading Democratic candidates

> has

> > > adopted the individual mandate, to varying degrees. Both

Clinton

> and

> > > require *all* Americans to obtain health coverage, but

> offers

> > > special exemptions " in cases of extreme financial hardship or

> religious

> > > beliefs. " And Obama's mandate applies only to children.

> > >

> > > Under Clinton, people would either retain their existing

coverage

> or

> > > select from one of two options: a broad array of private plans

> under the

> > > aegis of the Federal Employees Health Benefits Program (FEHBP)

or

> a

> > > Medicare-like public plan. Under , people not enrolled

in

> Medicare,

> > > Medicaid, SCHIP, or an employer-based program would be eligible

> to buy

> > > coverage through a series of regional Health Care Markets,

which

> would offer

> > > a choice between private and public coverage.

> > >

> > > Under Obama's plan, children would be eligible to remain in

their

> parents'

> > > plans up to age 25. And children in poorer families would be

> covered through

> > > Medicaid or SCHIP, which he would expand. For older Americans

> without

> > > coverage, Obama offers a public choice or a private one very

> similar to

> > > Clinton's and ', overseen by a " National Health

Insurance

> Exchange " -a

> > > sort of public watchdog. Obama would also offer subsidies in

the

> form of

> > > income-based tax credits to eligible individuals and families.

> > >

> > > A federal healthcare-for-all requirement holds little

attraction

> for the

> > > leading Republican candidates. None supports it-and several

> actively oppose

> > > it. " We do not believe in coercion and the use of state power

to

> mandate

> > > care, coverage, or costs, " McCain has said. To achieve more

> widespread

> > > coverage, front-runner Rudy Giuliani would improve and expand

> health savings

> > > accounts, as would Mitt Romney and Sen. McCain. For middle-

income

> Americans

> > > *without* employer-based coverage, Giuliani would offer an

income

> tax

> > > exclusion of up to $15,000. For those lower on the income

scale,

> he proposes

> > > a health insurance credit, presumably payable in advance, which

> could be

> > > coupled with either an employer contribution or a public

program,

> such as

> > > Medicaid.

> > >

> > > Like Giuliani, Romney would reform the tax code, including

> granting full

> > > deductibility for qualified medical expenses. Sen. McCain would

> expand

> > > private coverage by offering a $2,500 tax credit ($5,000 for

> families) to

> > > everyone with health insurance. Former Tennessee Sen. Fred

> 's plan

> > > is sketchy at this point, although, like his GOP colleagues, he

> favors a

> > > system built around " individual consumers " and " affordable

> healthcare

> > > options. "

> > >

> > > *Employer mandate. *Each of the leading Democrat's plans

requires

> > > employers to provide coverage for employees, although, here

> again, details

> > > differ. goes the furthest in this direction, requiring

> all employers

> > > either to cover their workers or help finance their health

> insurance. Both

> > > Clinton and Obama exempt small businesses from this mandate,

> although

> > > neither candidate has spelled out the precise size limits. To

> encourage

> > > small employers to provide coverage or continue offering it,

> Clinton's plan

> > > includes a tax credit.

> > >

> > > The leading Republicans favor a free-market approach, and are,

> therefore,

> > > as opposed to the employer mandate as they are to a requirement

> for

> > > individual coverage. As a group, their strategy is to shift as

> much money as

> > > possible from the employer-based group market to the individual

> market. The

> > > primary mechanism for doing this-as noted above-is through

> targeted changes

> > > in the tax code.

> > >

> > > *Medicaid and SCHIP. *All leading Democrats would expand or

> strengthen

> > > these two programs. , the only candidate to offer

> specifics, promises

> > > to provide enough federal funding to the states to permit them

to

> cover all

> > > children and parents under 250 percent of the federal poverty

> line, or about

> > > $50,000 for a family of four.

> > >

> > > As a group, the leading Republican candidates take a different

> tact.

> > > Rather than expand these public programs, their approach is to

> give states

> > > the flexibility to enact what Giuliani refers to as innovative

> changes.

> > > Romney would like to " block grant " federal Medicaid funds and

> remove

> > > " burdensome administrative requirements. " McCain would like

> states to use

> > > their Medicaid and SCHIP funds to help pay for private, rather

> than public,

> > > insurance.

> > >

> > > *Disease prevention and chronic care. *All of the leading

> Democrats

> > > include measures to address these two areas, both as something

> worthy in and

> > > of themselves and as part of their larger cost-saving

strategies.

> Clinton,

> > > for example, thinks billions could be saved by, among other

> things, offering

> > > proven preventive services to all Americans. Any private plan

> doing business

> > > with the government would be required to offer these services

> ( and

> > > Obama establish a similar requirement.) She'd also encourage,

as

> would

> > > , federally funded plans to establish continuing care

> > > innovations-including " medical homes. "

> > >

> > > The Republican candidates also weigh in on these two areas,

> albeit less

> > > specifically than their Democratic counterparts. Giuliani and

> think

> > > health insurance should be redefined to cover wellness and not

> just

> > > sickness. Giuliani would promote wellness programs and tie a

> state's

> > > Medicaid payments to how well it handled preventive care and

> childhood

> > > obesity. By encouraging personal responsibility, McCain would

try

> to prevent

> > > " expensive " chronic diseases. He would also focus more

attention

> on disease

> > > management rather than complex procedures by changing the way

> Medicare pays

> > > providers.

> > >

> > > *Evidence-based medicine. *All of the leading Democratic

> candidates would

> > > establish some kind of organization to collect and analyze best

> practices.

> > > suggests an agency within the Institute of Medicine,

> Clinton a

> > > federal-private " Best Practices Institute, " and Obama

> an " independent, "

> > > presumably nongovernmental institute.

> > >

> > > Two of the leading Republican candidates have addressed these

> issues

> > > directly, though generally. McCain wants to develop " national

> standards for

> > > measuring and recording treatments and outcomes, " while

> disallowing Medicare

> > > payments for " preventable medical errors. " wants to

> encourage " the

> > > widespread use of best practices. "

> > >

> > > *Information technology. *In the digital age, no forward-

thinking

> > > candidate can risk seeming indifferent to the hoped-for cost-

> savings and

> > > quality-improvement benefits of EHRs, electronic registries,

hand-

> held

> > > devices, and the like. Among the Democrats, Obama would invest

> $10 billion a

> > > year over the next five years-and Clinton $3 billion a year-to

> beef up the

> > > nation's IT infrastructure, while preserving patient privacy

> rights. Clinton

> > > also promises to give doctors financial incentives to adopt

> health IT.

> > > Though less specific about the dollars he'd invest,

seems

> equally

> > > committed to reducing the paper chase, while enforcing patient

> privacy

> > > protections.

> > >

> > > All of the leading Republicans touch on IT expansion as well.

> Giuliani,

> > > for example, calls for public-private partnerships to set the

> right

> > > standards, " without overbearing regulation. " McCain wants to

> promote the

> > > " rapid deployment of 21st century information systems. "

> > >

> > > *Drug costs. *All of the leading Democratic candidates would

> permit

> > > Medicare to negotiate lower drug prices. Both Clinton and Obama

> want to

> > > remove barriers to generic competition, and and Obama

> would open up

> > > drug reimportation. (While limits this measure to

Canada,

> Obama

> > > talks about including " developed countries " generally, under

> certain

> > > conditions.) Clinton would also " create a pathway to biogeneric

> competition "

> > > and more closely monitor the financial relationships between

> drugmakers and

> > > physicians.

> > >

> > > McCain is the only leading Republican candidate to hold out the

> > > possibility of controlling costs through the " safe

reimportation

> of drugs "

> > > and the " faster introduction " of generics. For his part,

Giuliani

> wants to

> > > reduce costs and save lives by streamlining the FDA approval

> process.

> > >

> > > *Medical malpractice. *Of the three Democratic candidates,

> Clinton is the

> > > only one whose plan doesn't touch on the issue directly. She

has

> previously

> > > supported liability protections for physicians who disclose

> errors and

> > > negotiate a fair compensation with patients, though. Besides a

> voluntary

> > > reporting system, , a former trial lawyer, supports

> mandatory

> > > sanctions against attorneys who file frivolous lawsuits, as

well

> as measures

> > > to beef up state medical boards. Obama talks about preventing

> medical

> > > liability insurers from charging doctors exorbitant rates,

among

> other

> > > things.

> > >

> > > Historically, medical malpractice has been a big issue for

> Republicans.

> > > Giuliani talks generally about ending frivolous lawsuits and

> excessive

> > > damage awards, without limiting compensation for real economic

> loss. Romney

> > > and McCain take more specific stands. Romney promises to push

for

> a federal

> > > cap on noneconomic and punitive awards, and McCain would like

to

> eliminate

> > > " frivolous lawsuits for doctors that follow clinical guidelines

> and adhere

> > > to patient safety protocols. "

> > >

> > > *Overall costs. *Rather than identifying what their plans would

> cost, the

> > > leading Democratic candidates focus on what they claim their

> plans would *

> > > save*. Among other things, Clinton would phase

out " overpayments "

> to

> > > Medicare Advantage plans ($10 billion), modernize the health

> system through

> > > IT adoption and other improvements ($35 billion), modify the

Bush

> tax cuts

> > > ($52 billion), and cap the medical benefits income tax

exclusion

> for

> > > households making more than $250,000 ($2 billion). In all, she

> asserts, she

> > > can save-and then reinvest back into the system-$110 billion.

> and

> > > Obama make only somewhat less optimistic projections.

> > >

> > > The Republicans talk about making the healthcare system more

> efficient

> > > through IT development and the like. But they place most of

their

> chips on

> > > the putative cost-saving benefits of consumer-directed

> healthcare. McCain

> > > makes the case this way: " American families know quality when

> they see it,

> > > so their dollars should be in their hands. " When it is,

> they're " less likely

> > > to choose the most expensive and often unnecessary options. "

> Families should

> > > be able to purchase healthcare coverage nationwide, across

state

> lines, both

> > > to maximize consumer choice and heighten competition for their

> business, he

> > > says.

> > >

> > > For many observers, neither the Democratic nor the Republican

> cost-savings

> > > proposals are up to the task. " Neither side has made any of the

> tougher

> > > efforts to try to restrain costs and spending, " says

> Blendon,

> > > professor of health policy and political analysis at Harvard.

The

> candidates

> > > have soft-pedaled the cost issue, Blendon says, not only

because

> it

> > > threatens interest groups-physicians, hospitals, drugmakers,

> insurers-but

> > > also because it threatens middle-income voters with the specter

> of limiting

> > > or rationing care.

> > >

> > > That specter *could* show up as part of future legislation, of

> course,

> > > depending on who's in power. Right now, though, the candidates

> are more

> > > concerned with laying out their visions-which, whatever else

they

> have going

> > > for them, will give voters a clear choice of direction.

> > >

> > > ------------------------------

> > > *From:* Practiceimprovement

> <mailto:%40yahoogroups.com> 1

> [mailto:Practiceimprovement

> <mailto:%40yahoogroups.com> 1 ]

> > > *On Behalf Of *mkcl6@

> > > *Sent:* Thursday, January 10, 2008 4:34 AM

> > > *To:* Practiceimprovement

> <mailto:%40yahoogroups.com> 1

> > > *Subject:* Re: France is healthcare

> leader, US

> > > comes dead last: study --> was RE: [Pract...

> > >

> > >

> > > I heard Mike Huckabee speak last fall, I think there are

several

> things I

> > > don't like about him, but he has his mind around health and

> prevention and

> > > REALLY seems to understand it. He doesn't seem to have a really

> well

> > > flushed out plan, but like I said, he had a deep and seemingly

> accurate

> > > understanding about health and prevention. Doesn't mean I'll

vote

> for him,

> > > but he is still on the table.

> > >

> > > Did anyone else review the table of the candidates views in

> Medical

> > > Economics? (I think that's where it was.) Kris

> > >

> > >

> > >

> > > ------------------------------

> > > Start the year off right. Easy ways to stay in

> shape<http://body. <http://body.aol.com/fitness/winter-exercise?>

> aol.com/fitness/winter-exercise?

> NCID=aolcmp00300000002489>in the new year.

> > >

> > >

> > >

> >

>

[Guest guest]

If forgot one other major thread in my historical documentary.

We went through a period in the early to mid 1990s where some of the

docs in our area

not only acquiesced to HMOs, they actually embraced them and

jumped into captitated managed care. These were mostly

the " entrepeneurial " types. They saw some of the early docs who got

in early as CEOs of some of the somewhat successful HMOs like

Pacificare getting mega millions, and thought they could do the

same and that they were so good at medicine that they could

manage the care and make even more than under fee for service.

We had an IPO group for about 3 years here before it folded. It was

amazing to see the naked greed come out in some of those IPO review

meetings you had to go to if you were on capitation. Docs who used to

send you nice letters when you referred somebody (perhaps after

making initial diagnostic blunders and possibly not sending a real good

history on the patient) - " Thank you Dr. Caldwell for this pleasant

patient with the very interesting problem " suddenly tell you what they

really thought about your referrals and where you could stick it, and to

manage the problem yourself. A lot of them started using the jargon

you might imagine in the board room of an HMO - like " We now have

5000 lives " and " How do we penetrate market the adjacent county?

They have an estimated 3500 lives. " etc., etc.

After a couple of years of the IPO meetings, they realized there was

never going to be a return of the " withold " on the captitation, in spite of

all the time spent " managing " care, and none of them were going to

become CEOs or be bought out by US Heathcare, so the whole thing

folded.

Now most ot the entrepeneurial docs have found that running networks

of Federally qualified Rural Health clinics in a CEO position is where

the action is.

> > >

> > >

> > > http://www.memag.com/memag/Medical+Economics/Election-

2008-

> Candidates-sound-off-on-

> healthcare/ArticleStandard/Article/detail/479378?

> contextCategoryId=8485

> > >

> > > This was out in december, so Huckabee didn't make the cut for

the

> table.

> > >

> > > Locke, MD

> > >

> > >

> > > <http://www.memag.com/> [image: Print]

> Election

> > > 2008: Candidates sound off on healthcare

> > > The major parties' leading presidential contenders would

> take the

> > > country in very different directions.

> > > Dec 21, 2007 By:Wayne J.

> Guglielmo<http://www.memag.com/memag/author/authorInfo.jsp?

id=6664>

> Medical

> > > Economics

> > >

> > > *To prepare for this article, Senior Editor Wayne J. Guglielmo

> reviewed

> > > the campaign materials of each of the candidates whose

positions

> are

> > > detailed below.*

> > >

> > > Few issues tap as deeply into the philosophical wellsprings of

> the two

> > > major parties as healthcare does.

> > >

> > > The partisan battle this fall over SCHIP-the State Children's

> Health

> > > Insurance Program-is a case in point, despite defections to the

> other side

> > > by typically loyal Republicans. (In mid-October, the House

upheld

> a

> > > presidential veto.) The philosophical divide is also evident in

> the

> > > presidential race, although even here there have been a few

> unexpected

> > > turns.

> > >

> > >

<http://www.memag.com/memag/content/printContentPopup.jsp?

> id=479378#>

> > > The candidates plans at a glance

> > > In various ways, the leading Democrats-Hillary Clinton (D-NY),

> Barack

> > > Obama (D-IL), and -rely partially on government

to

> guarantee a

> > > certain level of healthcare coverage to all Americans. For a

> party that's

> > > fond of using government muscle to solve big, hard social

> problems, this is

> > > pretty standard fare.

> > >

> > > And yet with the exception of Ohio Rep. Dennis Kucinich, none

of

> the

> > > Democratic candidates, leading or trailing, has tacked too far to

> the left

> > > in the primary campaigns in order to appeal to the party's

> traditionally

> > > liberal base. Sen. Clinton, for instance, does her best not to

> rock the boat

> > > of the millions of middle-income people who have employer-

based or

> > > individual insurance, and like it.

> > >

> > > In contrast, the leading Republican candidates-Rudy Giuliani,

Fred

> > > , Mitt Romney, and McCain (R-AZ)- have

cleaved

> fairly closely

> > > to the party's conservative base. Whether that will change in

the

> general

> > > election is unclear. (At press time, former Arkansas Gov. Mike

> Huckabee was

> > > rising in the GOP rankings.)

> > >

> > > What is clear is that, unlike the Democrats, the Republicans

want

> to

> > > minimize government's role, principally through a series of

taxed-

> based

> > > incentives that would encourage Americans to purchase health

> insurance on

> > > the private market. Even former Gov. Romney has thus far

tacked

> further to

> > > the right, declaring that his own Massachusetts health plan, a

> classic

> > > Republican-Democratic compromise, is not right for every state.

> > >

> > > *How the leading candidates compare*

> > >

> > > The leading Democrats seem eager this time around *not* to

repeat

> the

> > > mistakes of the early 1990s, when the first Clinton health plan,

> spearheaded

> > > by then First Lady Hillary Clinton, was rolled out. There's

> greater emphasis

> > > now on choice, shared responsibility, and affordability. And

> though each of

> > > the leading candidates still wants universal coverage, the

> mechanisms by

> > > which they would reach that ambitious goal, many observers

point

> out, have

> > > changed significantly.

> > >

> > > Not significantly enough, say the Republicans. Former Gov.

> Romney's

> > > response to Hillary Clinton's plan typifies their reaction: " It's

> government

> > > insurance, not private insurance. . . . It's a European-style

> socialized

> > > medicine plan-that's where it leads-and that's the wrong

> direction for

> > > America. "

> > >

> > > *Universal coverage. *Each of the leading Democratic

candidates

> has

> > > adopted the individual mandate, to varying degrees. Both

Clinton

> and

> > > require *all* Americans to obtain health coverage, but

> offers

> > > special exemptions " in cases of extreme financial hardship or

> religious

> > > beliefs. " And Obama's mandate applies only to children.

> > >

> > > Under Clinton, people would either retain their existing coverage

> or

> > > select from one of two options: a broad array of private plans

> under the

> > > aegis of the Federal Employees Health Benefits Program

(FEHBP) or

> a

> > > Medicare-like public plan. Under , people not enrolled in

> Medicare,

> > > Medicaid, SCHIP, or an employer-based program would be

eligible

> to buy

> > > coverage through a series of regional Health Care Markets,

which

> would offer

> > > a choice between private and public coverage.

> > >

> > > Under Obama's plan, children would be eligible to remain in their

> parents'

> > > plans up to age 25. And children in poorer families would be

> covered through

> > > Medicaid or SCHIP, which he would expand. For older

Americans

> without

> > > coverage, Obama offers a public choice or a private one very

> similar to

> > > Clinton's and ', overseen by a " National Health

Insurance

> Exchange " -a

> > > sort of public watchdog. Obama would also offer subsidies in

the

> form of

> > > income-based tax credits to eligible individuals and families.

> > >

> > > A federal healthcare-for-all requirement holds little attraction

> for the

> > > leading Republican candidates. None supports it-and several

> actively oppose

> > > it. " We do not believe in coercion and the use of state power to

> mandate

> > > care, coverage, or costs, " McCain has said. To achieve more

> widespread

> > > coverage, front-runner Rudy Giuliani would improve and expand

> health savings

> > > accounts, as would Mitt Romney and Sen. McCain. For middle-

income

> Americans

> > > *without* employer-based coverage, Giuliani would offer an

income

> tax

> > > exclusion of up to $15,000. For those lower on the income

scale,

> he proposes

> > > a health insurance credit, presumably payable in advance,

which

> could be

> > > coupled with either an employer contribution or a public

program,

> such as

> > > Medicaid.

> > >

> > > Like Giuliani, Romney would reform the tax code, including

> granting full

> > > deductibility for qualified medical expenses. Sen. McCain would

> expand

> > > private coverage by offering a $2,500 tax credit ($5,000 for

> families) to

> > > everyone with health insurance. Former Tennessee Sen. Fred

> 's plan

> > > is sketchy at this point, although, like his GOP colleagues, he

> favors a

> > > system built around " individual consumers " and " affordable

> healthcare

> > > options. "

> > >

> > > *Employer mandate. *Each of the leading Democrat's plans

requires

> > > employers to provide coverage for employees, although, here

> again, details

> > > differ. goes the furthest in this direction, requiring

> all employers

> > > either to cover their workers or help finance their health

> insurance. Both

> > > Clinton and Obama exempt small businesses from this

mandate,

> although

> > > neither candidate has spelled out the precise size limits. To

> encourage

> > > small employers to provide coverage or continue offering it,

> Clinton's plan

> > > includes a tax credit.

> > >

> > > The leading Republicans favor a free-market approach, and are,

> therefore,

> > > as opposed to the employer mandate as they are to a

requirement

> for

> > > individual coverage. As a group, their strategy is to shift as

> much money as

> > > possible from the employer-based group market to the

individual

> market. The

> > > primary mechanism for doing this-as noted above-is through

> targeted changes

> > > in the tax code.

> > >

> > > *Medicaid and SCHIP. *All leading Democrats would expand or

> strengthen

> > > these two programs. , the only candidate to offer

> specifics, promises

> > > to provide enough federal funding to the states to permit them

to

> cover all

> > > children and parents under 250 percent of the federal poverty

> line, or about

> > > $50,000 for a family of four.

> > >

> > > As a group, the leading Republican candidates take a different

> tact.

> > > Rather than expand these public programs, their approach is to

> give states

> > > the flexibility to enact what Giuliani refers to as innovative

> changes.

> > > Romney would like to " block grant " federal Medicaid funds and

> remove

> > > " burdensome administrative requirements. " McCain would like

> states to use

> > > their Medicaid and SCHIP funds to help pay for private, rather

> than public,

> > > insurance.

> > >

> > > *Disease prevention and chronic care. *All of the leading

> Democrats

> > > include measures to address these two areas, both as

something

> worthy in and

> > > of themselves and as part of their larger cost-saving strategies.

> Clinton,

> > > for example, thinks billions could be saved by, among other

> things, offering

> > > proven preventive services to all Americans. Any private plan

> doing business

> > > with the government would be required to offer these services

> ( and

> > > Obama establish a similar requirement.) She'd also encourage,

as

> would

> > > , federally funded plans to establish continuing care

> > > innovations-including " medical homes. "

> > >

> > > The Republican candidates also weigh in on these two areas,

> albeit less

> > > specifically than their Democratic counterparts. Giuliani and

> think

> > > health insurance should be redefined to cover wellness and not

> just

> > > sickness. Giuliani would promote wellness programs and tie a

> state's

> > > Medicaid payments to how well it handled preventive care and

> childhood

> > > obesity. By encouraging personal responsibility, McCain would

try

> to prevent

> > > " expensive " chronic diseases. He would also focus more

attention

> on disease

> > > management rather than complex procedures by changing the

way

> Medicare pays

> > > providers.

> > >

> > > *Evidence-based medicine. *All of the leading Democratic

> candidates would

> > > establish some kind of organization to collect and analyze best

> practices.

> > > suggests an agency within the Institute of Medicine,

> Clinton a

> > > federal-private " Best Practices Institute, " and Obama

> an " independent, "

> > > presumably nongovernmental institute.

> > >

> > > Two of the leading Republican candidates have addressed

these

> issues

> > > directly, though generally. McCain wants to develop " national

> standards for

> > > measuring and recording treatments and outcomes, " while

> disallowing Medicare

> > > payments for " preventable medical errors. " wants to

> encourage " the

> > > widespread use of best practices. "

> > >

> > > *Information technology. *In the digital age, no forward-thinking

> > > candidate can risk seeming indifferent to the hoped-for cost-

> savings and

> > > quality-improvement benefits of EHRs, electronic registries,

hand-

> held

> > > devices, and the like. Among the Democrats, Obama would

invest

> $10 billion a

> > > year over the next five years-and Clinton $3 billion a year-to

> beef up the

> > > nation's IT infrastructure, while preserving patient privacy

> rights. Clinton

> > > also promises to give doctors financial incentives to adopt

> health IT.

> > > Though less specific about the dollars he'd invest,

seems

> equally

> > > committed to reducing the paper chase, while enforcing patient

> privacy

> > > protections.

> > >

> > > All of the leading Republicans touch on IT expansion as well.

> Giuliani,

> > > for example, calls for public-private partnerships to set the

> right

> > > standards, " without overbearing regulation. " McCain wants to

> promote the

> > > " rapid deployment of 21st century information systems. "

> > >

> > > *Drug costs. *All of the leading Democratic candidates would

> permit

> > > Medicare to negotiate lower drug prices. Both Clinton and

Obama

> want to

> > > remove barriers to generic competition, and and

Obama

> would open up

> > > drug reimportation. (While limits this measure to

Canada,

> Obama

> > > talks about including " developed countries " generally, under

> certain

> > > conditions.) Clinton would also " create a pathway to biogeneric

> competition "

> > > and more closely monitor the financial relationships between

> drugmakers and

> > > physicians.

> > >

> > > McCain is the only leading Republican candidate to hold out the

> > > possibility of controlling costs through the " safe reimportation

> of drugs "

> > > and the " faster introduction " of generics. For his part, Giuliani

> wants to

> > > reduce costs and save lives by streamlining the FDA approval

> process.

> > >

> > > *Medical malpractice. *Of the three Democratic candidates,

> Clinton is the

> > > only one whose plan doesn't touch on the issue directly. She

has

> previously

> > > supported liability protections for physicians who disclose

> errors and

> > > negotiate a fair compensation with patients, though. Besides a

> voluntary

> > > reporting system, , a former trial lawyer, supports

> mandatory

> > > sanctions against attorneys who file frivolous lawsuits, as well

> as measures

> > > to beef up state medical boards. Obama talks about preventing

> medical

> > > liability insurers from charging doctors exorbitant rates, among

> other

> > > things.

> > >

> > > Historically, medical malpractice has been a big issue for

> Republicans.

> > > Giuliani talks generally about ending frivolous lawsuits and

> excessive

> > > damage awards, without limiting compensation for real

economic

> loss. Romney

> > > and McCain take more specific stands. Romney promises to

push for

> a federal

> > > cap on noneconomic and punitive awards, and McCain would

like to

> eliminate

> > > " frivolous lawsuits for doctors that follow clinical guidelines

> and adhere

> > > to patient safety protocols. "

> > >

> > > *Overall costs. *Rather than identifying what their plans would

> cost, the

> > > leading Democratic candidates focus on what they claim their

> plans would *

> > > save*. Among other things, Clinton would phase

out " overpayments "

> to

> > > Medicare Advantage plans ($10 billion), modernize the health

> system through

> > > IT adoption and other improvements ($35 billion), modify the

Bush

> tax cuts

> > > ($52 billion), and cap the medical benefits income tax exclusion

> for

> > > households making more than $250,000 ($2 billion). In all, she

> asserts, she

> > > can save-and then reinvest back into the system-$110 billion.

> and

> > > Obama make only somewhat less optimistic projections.

> > >

> > > The Republicans talk about making the healthcare system more

> efficient

> > > through IT development and the like. But they place most of

their

> chips on

> > > the putative cost-saving benefits of consumer-directed

> healthcare. McCain

> > > makes the case this way: " American families know quality

when

> they see it,

> > > so their dollars should be in their hands. " When it is,

> they're " less likely

> > > to choose the most expensive and often unnecessary options. "

> Families should

> > > be able to purchase healthcare coverage nationwide, across

state

> lines, both

> > > to maximize consumer choice and heighten competition for

their

> business, he

> > > says.

> > >

> > > For many observers, neither the Democratic nor the Republican

> cost-savings

> > > proposals are up to the task. " Neither side has made any of the

> tougher

> > > efforts to try to restrain costs and spending, " says

> Blendon,

> > > professor of health policy and political analysis at Harvard. The

> candidates

> > > have soft-pedaled the cost issue, Blendon says, not only

because

> it

> > > threatens interest groups-physicians, hospitals, drugmakers,

> insurers-but

> > > also because it threatens middle-income voters with the specter

> of limiting

> > > or rationing care.

> > >

> > > That specter *could* show up as part of future legislation, of

> course,

> > > depending on who's in power. Right now, though, the candidates

> are more

> > > concerned with laying out their visions-which, whatever else

they

> have going

> > > for them, will give voters a clear choice of direction.

> > >

> > > ------------------------------

> > > *From:*

> [mailto: ]

> > > *On Behalf Of *mkcl6@

> > > *Sent:* Thursday, January 10, 2008 4:34 AM

> > > *To:*

> > > *Subject:* Re: France is healthcare

> leader, US

> > > comes dead last: study --> was RE: [Pract...

> > >

> > >

> > > I heard Mike Huckabee speak last fall, I think there are several

> things I

> > > don't like about him, but he has his mind around health and

> prevention and

> > > REALLY seems to understand it. He doesn't seem to have a

really

> well

> > > flushed out plan, but like I said, he had a deep and seemingly

> accurate

> > > understanding about health and prevention. Doesn't mean I'll

vote

> for him,

> > > but he is still on the table.

> > >

> > > Did anyone else review the table of the candidates views in

> Medical

> > > Economics? (I think that's where it was.) Kris

> > >

> > >

> > >

> > > ------------------------------

> > > Start the year off right. Easy ways to stay in

> shape<http://body.aol.com/fitness/winter-exercise?

> NCID=aolcmp00300000002489>in the new year.

> > >

> > >

> > >

> >

>

[Guest guest]

Elaine,

I appreciate your words of experience from the Canadian

system. I absolutely agree with your business owner friend – the insurance

mandates put forth by , Obama, & Clinton (and Nixon, as some people

may remember) seem to me essentially subsidizations for the insurance industry,

not at all a feasible program to ensure universal health care. (see my earlier

post re my thoughts on the best way to move forward with universal health care –

a singe-payer nat’l healt insurance program.)

Take care,

-emily

Queenan, MD

Chief Resident, Department of Family

Medicine

777

S. Clinton Ave

Rochester, NY 14602

Clinical Practice:

Brown Sq Health Center

322

Lake Ave

Rochester, NY 14608

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result in a fine or jail sentence or both.

[Guest guest]

So,

to sum up the change in the payer system over the past 15-20 years. (medicare not

included)

-

in the beginning, the patient

would pay the MD for services provided and the patient would be reimbursed a percentage

by the insurance company. If there was a problem, the patient would deal with

the insurer with the help of the MD if necessary.

-

Then, the insurance companies

developed the idea of capitation, where a physician would be paid a certain amount

per month per patient no matter how often they saw the patient. The patient

would pay the MD a copay for each visit under this system.

-

Now, full capitation never

really was successful and a hybrid system developed in which the patient pays a

copay per visit and the MD bills the insurance company a discounted rate.

If a problem with payment occurs the MD must complain to the insurer to get the

payment they earned. (Although recent posts here indicate that some IMPs

hold the patient responsible if the insurer doesn’t pay, at least with Tricare/Medicare

patients. I think some insurers’ contracts prevent the MD from

seeking payment from the patient if refused by the insurer.)

Basically

the insurer’s have decreased their payment to physicians, kept the

patient’s out of pocket cost relatively inexpensive, and have moved the

onus of collecting reimbursement from the patients to the MDs. A great

bonus because if millions of Americans complained to their congresspersons that

the insurance companies were delaying their reimbursement, requiring redundant

paperwork and generally not dealing in good faith, there would be hearings all

over capitol hill. But this won’t happen, because it’s only

tens of thousands of doctors (who the patients may perceive as money grubbing

anyway) complaining; and the insurance companies own the politicos through

campaign donations and lobbyists.

Straz

* Re: France is healthcare

> leader, US

> > > comes dead last: study --> was RE: [Pract...

> > >

> > >

> > > I heard Mike Huckabee speak last fall, I think there are several

> things I

> > > don't like about him, but he has his mind around health and

> prevention and

> > > REALLY seems to understand it. He doesn't seem to have a

really

> well

> > > flushed out plan, but like I said, he had a deep and seemingly

> accurate

> > > understanding about health and prevention. Doesn't mean I'll

vote

> for him,

> > > but he is still on the table.

> > >

> > > Did anyone else review the table of the candidates views in

> Medical

> > > Economics? (I think that's where it was.) Kris

> > >

> > >

> > >

> > > ------------------------------

> > > Start the year off right. Easy ways to stay in

> shape<http://body.aol.com/fitness/winter-exercise?

> NCID=aolcmp00300000002489>in the new year.

> > >

> > >

> > >

> >

>

[Guest guest]

Every time someone talks of Health Maintenance Accounts for everyone, I think of Derf (not his real name), who lives in a three wheel on Mainstreet near by, and makes his income washing peoples cars, trading junk he picked up, and has to be helped to find his home if he has a couple of drinks in the bar. He's not organized enough to get on Medicare. As far as he is concerned he is fine. He has an old collarbone fracture with a callus the size of a duck's egg, and his left hand has an wrist fracture that reminds you of a spoon from when he was hit by a truck and left for the night by the side of the road. You want him to open an account with....what? Joanne, the Old MD in Drain, Oregon wrote: What do you think of catastrophic care (however that would be defined) for everyone and use of health maintenance accounts for primary care? So for pirmary care at least, we can be paid directly by our pts and we cut the middle man, the insurance companies. That should save some money in the system. Thanx for your input. On 1/12/08, <elaine2mdgmail> wrote: I have been following this listserve for the last

few months. Finally gave notice at my HMO where I have been for 12 years that I will be leaving in April to start an IMP. This listserve has been a tremendous inspiration. Everytime I feel like I am making a mistake, I remind myself how this group if full of physicians who are happy with this same decision that I am now making. But then maybe the unhappy ones are not on this listserve (joke). Prior to practicing in Los Angeles, I use to be an FP in Toronto, Canada. So I have to comment that is it not reasonable to think that Canada can supply Americans with their drugs. Firstly, with the Canadian dollar at par, their drugs are not that cheap. Secondly, if I remember this correctly, Canada consumes 1% of the Rx drugs in the world whereas America consumes 50% of the Rx drugs. Canada's small population, can't save America's disfunctional health care system. My greatest disappointment in our health care system

is how private insurance has us doctors by the noose. I feel like we are their puppet's. How this evolved among a group of people who are naturally independant and trained to be leaders is beyond me. It's a sad situation. How did the FP here end up giving up their freedom? Even though Canada's health care system has a top down system, most doctors are like IMP. So becoming an IMP is like going back to my roots. I am not quite sure how all this insurance stuff works so I am going to take a short billing course. I am leaning toward cash up front and help pt bill their insurance so pt can be paid directly by their insurer. I don't want to be a slave to these insurance companies and all their rules, telling me how I have to do this or that. Maybe I will starve but looks like my rates will be be lower than the local Minute Clinic. I have a friend who is a successful business owner who objects to government mandating businesses to buy health

insurance because its not right that the government or anyone legislate that he buy something from another private company. Its would be a winfall for these private insurance companies who are not our friends. If people are forced to buy something, then it should be from a non profit of some sort. What do you all think? On 1/10/08, Locke's in Colorado <lockekcomcast (DOT) net > wrote: http://www.memag.com/memag/Medical+Economics/Election-2008-Candidates-sound-off-on-healthcare/ArticleStandard/Article/detail/479378?contextCategoryId=8485 This was out in december, so Huckabee didn't make the cut for the table. Locke, MD Election 2008: Candidates sound off on healthcare The major parties' leading presidential contenders would take the country in very different directions. Dec 21, 2007 By:Wayne J. Guglielmo Medical Economics To prepare for this article, Senior Editor Wayne J. Guglielmo reviewed the campaign materials of each of the candidates whose positions are detailed below. Few issues tap as deeply into the philosophical wellsprings of the two major parties as healthcare does. The partisan battle this fall over SCHIP—the State Children's Health Insurance Program—is a case in point,

despite defections to the other side by typically loyal Republicans. (In mid-October, the House upheld a presidential veto.) The philosophical divide is also evident in the presidential race, although even here there have been a few unexpected turns. The candidates plans at a glanceIn various ways, the leading Democrats—Hillary Clinton (D-NY), Barack Obama (D-IL), and —rely partially on government to guarantee a certain level of healthcare coverage to all Americans. For a party that's fond of using government muscle to solve big, hard social problems, this is pretty standard fare. And yet with the

exception of Ohio Rep. Dennis Kucinich, none of the Democratic candidates, leading or trailing, has tacked too far to the left in the primary campaigns in order to appeal to the party's traditionally liberal base. Sen. Clinton, for instance, does her best not to rock the boat of the millions of middle-income people who have employer-based or individual insurance, and like it. In contrast, the leading Republican candidates—Rudy Giuliani, Fred , Mitt Romney, and McCain (R-AZ)— have cleaved fairly closely to the party's conservative base. Whether that will change in the general election is unclear. (At press time, former Arkansas Gov. Mike Huckabee was rising in the GOP rankings.) What is clear is that, unlike the Democrats, the Republicans want to minimize government's role, principally through a series of taxed-based incentives that would encourage Americans to purchase health insurance on the private market.

Even former Gov. Romney has thus far tacked further to the right, declaring that his own Massachusetts health plan, a classic Republican-Democratic compromise, is not right for every state. How the leading candidates compare The leading Democrats seem eager this time around not to repeat the mistakes of the early 1990s, when the first Clinton health plan, spearheaded by then First Lady Hillary Clinton, was rolled out. There's greater emphasis now on choice, shared responsibility, and affordability. And though each of the leading candidates still wants universal coverage, the mechanisms by which they would reach that ambitious goal, many observers point out, have changed significantly. Not significantly enough, say the Republicans. Former Gov. Romney's response to Hillary Clinton's plan typifies their reaction: "It's government insurance, not private insurance. . . .

It's a European-style socialized medicine plan—that's where it leads—and that's the wrong direction for America." Universal coverage. Each of the leading Democratic candidates has adopted the individual mandate, to varying degrees. Both Clinton and require all Americans to obtain health coverage, but offers special exemptions "in cases of extreme financial hardship or religious beliefs." And Obama's mandate applies only to children. Under Clinton, people would either retain their existing coverage or select from one of two options: a broad array of private plans under the aegis of the Federal Employees Health Benefits Program (FEHBP) or a Medicare-like public plan. Under , people not enrolled in Medicare, Medicaid, SCHIP, or an employer-based program would be eligible to buy coverage through a series of regional Health Care Markets, which would offer a choice between private and public

coverage. Under Obama's plan, children would be eligible to remain in their parents' plans up to age 25. And children in poorer families would be covered through Medicaid or SCHIP, which he would expand. For older Americans without coverage, Obama offers a public choice or a private one very similar to Clinton's and ', overseen by a "National Health Insurance Exchange"—a sort of public watchdog. Obama would also offer subsidies in the form of income-based tax credits to eligible individuals and families. A federal healthcare-for-all requirement holds little attraction for the leading Republican candidates. None supports it—and several actively oppose it. "We do not believe in coercion and the use of state power to mandate care, coverage, or costs," McCain has said. To achieve more widespread coverage, front-runner Rudy Giuliani would improve and expand health savings accounts, as would Mitt Romney and

Sen. McCain. For middle-income Americans without employer-based coverage, Giuliani would offer an income tax exclusion of up to $15,000. For those lower on the income scale, he proposes a health insurance credit, presumably payable in advance, which could be coupled with either an employer contribution or a public program, such as Medicaid. Like Giuliani, Romney would reform the tax code, including granting full deductibility for qualified medical expenses. Sen. McCain would expand private coverage by offering a $2,500 tax credit ($5,000 for families) to everyone with health insurance. Former Tennessee Sen. Fred 's plan is sketchy at this point, although, like his GOP colleagues, he favors a system built around "individual consumers" and "affordable healthcare options." Employer mandate. Each of the leading Democrat's plans requires employers to provide coverage for employees, although, here again,

details differ. goes the furthest in this direction, requiring all employers either to cover their workers or help finance their health insurance. Both Clinton and Obama exempt small businesses from this mandate, although neither candidate has spelled out the precise size limits. To encourage small employers to provide coverage or continue offering it, Clinton's plan includes a tax credit. The leading Republicans favor a free-market approach, and are, therefore, as opposed to the employer mandate as they are to a requirement for individual coverage. As a group, their strategy is to shift as much money as possible from the employer-based group market to the individual market. The primary mechanism for doing this—as noted above—is through targeted changes in the tax code. Medicaid and SCHIP. All leading Democrats would expand or strengthen these two programs. , the only candidate to offer specifics,

promises to provide enough federal funding to the states to permit them to cover all children and parents under 250 percent of the federal poverty line, or about $50,000 for a family of four. As a group, the leading Republican candidates take a different tact. Rather than expand these public programs, their approach is to give states the flexibility to enact what Giuliani refers to as innovative changes. Romney would like to "block grant" federal Medicaid funds and remove "burdensome administrative requirements." McCain would like states to use their Medicaid and SCHIP funds to help pay for private, rather than public, insurance. Disease prevention and chronic care. All of the leading Democrats include measures to address these two areas, both as something worthy in and of themselves and as part of their larger cost-saving strategies. Clinton, for example, thinks billions could be saved by, among other things,

offering proven preventive services to all Americans. Any private plan doing business with the government would be required to offer these services ( and Obama establish a similar requirement.) She'd also encourage, as would , federally funded plans to establish continuing care innovations—including "medical homes." The Republican candidates also weigh in on these two areas, albeit less specifically than their Democratic counterparts. Giuliani and think health insurance should be redefined to cover wellness and not just sickness. Giuliani would promote wellness programs and tie a state's Medicaid payments to how well it handled preventive care and childhood obesity. By encouraging personal responsibility, McCain would try to prevent "expensive" chronic diseases. He would also focus more attention on disease management rather than complex procedures by changing the way Medicare pays providers.

Evidence-based medicine. All of the leading Democratic candidates would establish some kind of organization to collect and analyze best practices. suggests an agency within the Institute of Medicine, Clinton a federal-private "Best Practices Institute," and Obama an "independent," presumably nongovernmental institute. Two of the leading Republican candidates have addressed these issues directly, though generally. McCain wants to develop "national standards for measuring and recording treatments and outcomes," while disallowing Medicare payments for "preventable medical errors." wants to encourage "the widespread use of best practices." Information technology. In the digital age, no forward-thinking candidate can risk seeming indifferent to the hoped-for cost-savings and quality-improvement benefits of EHRs, electronic registries, hand-held devices, and the like. Among the

Democrats, Obama would invest $10 billion a year over the next five years—and Clinton $3 billion a year—to beef up the nation's IT infrastructure, while preserving patient privacy rights. Clinton also promises to give doctors financial incentives to adopt health IT. Though less specific about the dollars he'd invest, seems equally committed to reducing the paper chase, while enforcing patient privacy protections. All of the leading Republicans touch on IT expansion as well. Giuliani, for example, calls for public-private partnerships to set the right standards, "without overbearing regulation." McCain wants to promote the "rapid deployment of 21st century information systems." Drug costs. All of the leading Democratic candidates would permit Medicare to negotiate lower drug prices. Both Clinton and Obama want to remove barriers to generic competition, and and Obama would open up drug reimportation.

(While limits this measure to Canada, Obama talks about including "developed countries" generally, under certain conditions.) Clinton would also "create a pathway to biogeneric competition" and more closely monitor the financial relationships between drugmakers and physicians. McCain is the only leading Republican candidate to hold out the possibility of controlling costs through the "safe reimportation of drugs" and the "faster introduction" of generics. For his part, Giuliani wants to reduce costs and save lives by streamlining the FDA approval process. Medical malpractice. Of the three Democratic candidates, Clinton is the only one whose plan doesn't touch on the issue directly. She has previously supported liability protections for physicians who disclose errors and negotiate a fair compensation with patients, though. Besides a voluntary reporting system, , a former trial lawyer, supports

mandatory sanctions against attorneys who file frivolous lawsuits, as well as measures to beef up state medical boards. Obama talks about preventing medical liability insurers from charging doctors exorbitant rates, among other things. Historically, medical malpractice has been a big issue for Republicans. Giuliani talks generally about ending frivolous lawsuits and excessive damage awards, without limiting compensation for real economic loss. Romney and McCain take more specific stands. Romney promises to push for a federal cap on noneconomic and punitive awards, and McCain would like to eliminate "frivolous lawsuits for doctors that follow clinical guidelines and adhere to patient safety protocols." Overall costs. Rather than identifying what their plans would cost, the leading Democratic candidates focus on what they claim their plans would save. Among other things, Clinton would phase out "overpayments"

to Medicare Advantage plans ($10 billion), modernize the health system through IT adoption and other improvements ($35 billion), modify the Bush tax cuts ($52 billion), and cap the medical benefits income tax exclusion for households making more than $250,000 ($2 billion). In all, she asserts, she can save—and then reinvest back into the system—$110 billion. and Obama make only somewhat less optimistic projections. The Republicans talk about making the healthcare system more efficient through IT development and the like. But they place most of their chips on the putative cost-saving benefits of consumer-directed healthcare. McCain makes the case this way: "American families know quality when they see it, so their dollars should be in their hands." When it is, they're "less likely to choose the most expensive and often unnecessary options." Families should be able to purchase healthcare coverage nationwide, across state lines, both to

maximize consumer choice and heighten competition for their business, he says. For many observers, neither the Democratic nor the Republican cost-savings proposals are up to the task. "Neither side has made any of the tougher efforts to try to restrain costs and spending," says Blendon, professor of health policy and political analysis at Harvard. The candidates have soft-pedaled the cost issue, Blendon says, not only because it threatens interest groups—physicians, hospitals, drugmakers, insurers—but also because it threatens middle-income voters with the specter of limiting or rationing care. That specter could show up as part of future legislation, of course, depending on who's in power. Right now, though, the candidates are more concerned with laying out their visions—which, whatever else they have going for them, will give voters a clear choice of direction. From: [mailto: ] On Behalf Of mkcl6@...Sent: Thursday, January 10, 2008 4:34 AM To: Subject: Re: France is healthcare leader, US comes dead last: study --> was RE: [Pract... I heard Mike Huckabee speak last fall, I think there are several things I don't like about him, but he has his mind around health and

prevention and REALLY seems to understand it. He doesn't seem to have a really well flushed out plan, but like I said, he had a deep and seemingly accurate understanding about health and prevention. Doesn't mean I'll vote for him, but he is still on the table. Did anyone else review the table of the candidates views in Medical Economics? (I think that's where it was.) Kris Start the year off right. Easy ways to stay in shape in the new year.

-- M.D.www.elainemd.com

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