Politics - Health Care - US

[Guest guest]

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

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 AMTo: 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

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