Rhetoric and Policies that Don’t Match

For a strange moment in US politics, the Prez debate the other night, the candidates were asked whether they thought health care was a right or not?

McCain answered health care is a responsibility.  Obama right.

But then you read this article by Ron Brownstein and something doesn’t add up:

The bedrock goal of Obama’s plan is to reinforce the sharing of risk and cost between healthy and sick, young and old. By contrast, McCain, hoping to expand choice, would erode risk-sharing and accept sharper distinctions between the healthy and sick in both the availability and cost of coverage. One plan prizes solidarity; the other, autonomy.

iow, the language and the policies don’t add up.  Obama’s plan is one predicted on responsibility (mutual responsibility I guess).  And McCain’s is rightly seen by Brownstein as emphasizing autonomy (more traditionally connected with the language of rights).

I think it’s much better to talk about health care as a responsibility or a democratically approved common good and not a right.  So in that sense, I’m with McCain.

But McCain’s plan is really more about individual responsibility I guess you could say (charitably?).  Except that for a large number of individuals (see Brownstein’s post for background on this) they won’t have that opportunity because the market will not be available to them (pre-existing conditions, the state de-regulation McCain pushes could allow states to take up residence in a state with lax regulation and sell that policy everywhere). So Obama’s argument for rights I suppose is that he will use the power of the fed to enforce the companies to see to it that those rights are upheld.  Maybe?

I don’t know, I find the languaging on both sides pretty weird.

Published in: on October 11, 2008 at 9:40 am  Leave a Comment  
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Sick Around the World

PBS Frontline documentary Sick Around the World. The video above is part 1/8, you can follow the links to the rest on the YouTube site.

The Documentary goes to countries around the world to study their health care systems–Great Britain, Japan, Germany, Taiwan (which studied everyone else’s for their reforms a decade ago), and Switzerland.

The doc does a good job of showing the strengths and weaknesses of each system. e.g., Britain does preventive care very well but has longer wait times for surgeries. Japan has amazing care (including house calls!!!!) but the government is setting the prices too low and therefore many hospitals are in the red.

Canada where I live, which is not in the film, is suffering from a shortage of doctors.

The US however has the most expensive system in the world which ranks 37th. The lowest of industrialized countries by far. And again is the most expensive (the free market for you). You hear people in the movie say that health care is a right; I don’t think legally that is a good way to go (at least in the American context). Better to argue it is a legislated social good, i.e. something society places a priority on and wants to fund.

McCain’s push towards a more market friendly, Health Savings Account, and destruction of the employer model of health care (which I support but to replaced by something else, McCain just destroys and leaves nothing in its wake) does not get at a core flaw in the US system: the ability of HSA, insurance companies and the like to deny coverage based on prior conditions.

As you see in the movie all of the countries through different mechanisms force insurers to cover (as well as mandate citizens to have coverage). What you also notice in the documentary is that they are getting better care for their buck.

A key point the film makes is that the US has elements of all these systems as well as Third World reality (i.e. uninsured) in the country. The Third World side of American care is what causes the massive cost of this massively inefficient system. A system McCain’s policies would make only massively more inefficient btw.

Now that being said, government care which can include (a la Germany and Switzerland) huge amounts of privatization (clinics, doctors, hospitals, insurers) has flaws. Every system does. There is no perfection, but there is certainly better and much better.  I think for a number of reasons, especially for US, the German, Swiss (French are on this model in some variation as well) is more a way to go.  Over say the NHS in Britain or the Single Payer System in Canada (and with modifications Taiwan).

Published in: on June 20, 2008 at 9:20 am  Comments (1)  
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Obama´s First Hundred Days

Interesting piece from Marc Ambinder.

At a fundraiser in Denver last night, Sen. Barack Obama signaled that he would use the grace period of his first 100 days in office to push through national health insurance plan. In general, a fresh administration is given some latitude to pursue a single domestic policy goal; think of George W. Bush and No Child Left Behind — although Democrats were a bit shell-shocked then.


NB: Other Obama 100 day priorities include a “signal to the world” on energy and climate change, and a review of every Bush executive order.

First off this is semi if not outright ludicrous.  In three months of taking power you are not going to get through health care, climate change, and executive orders.  Not with the absolute mess the bureaucracy will be at the end of the Bush days.  You think it´s crazy there now with everybody jumping ship and writing books that slam the Chief, wait til November, December.  It´s going to be the looney bin then.

Second, why can´t we go to the days when Congress actually initiated and started legislation and the Executive just either vetoed or signed and executed the law?  Why not have Obama signal basic principles he would like to see in a health care bill and then let the Congress deal with the specifics as it is Constitutionally mandated to do?  Note this would not be any different with McCain.  It´s a sign of how much that mentality has been lost that both parties adhere to the same MO though with different goals and policies in mind of course.  The Wyden-Bennett bipartisan health care plan would be the way to go in this manner imo.

But the point about restoring the executive branch to integrity starting with the Department of Justice, reviewing every Bush decision and overturning those that are unconstitutional would be extremely welcome on this end.

Published in: on May 29, 2008 at 11:29 am  Leave a Comment  
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Klein on 2 Proposals in US Health Care

Ezra Klein does a really helpful job outlining both the policy philosophy and the practical political hurdles to health care reform. He discusses Jacob Hacker’s Health Care for America Plan, a form of which is influential in both Clinton’s and Obama’s health care plan (even including the difference over individual mandates). On the other is the bipartisan Wyden-Bennett plan. I’ve highlighed Klein’s analysis of the Wyden plan before (here).

The third alternative, which Klein as a liberal is not really considering (bc he thinks it’s ludicrous and unworkable) though he briefly mentions is the McCain Health Care plan. The flaw in McCain’s plan is that it shifts costs to individuals and allows health insurance companies to set parameters–particularly around rejecting applicants based on prior illnesses and so forth. So while McCain invokes the specter of Canada in the time-worn tradition of US conservatives to scare Americans into thinking there will be long waiting lines with socialist Obama/Clinton plans while you are dying so bureaucrats can count some beans, McCain’s plan in effect (analysis here) will (as Klein says) price care out of the reach of millions more of Americans, particularly as the Boomer retirement push comes. There’s a cap, it simply isn’t set by the government but rather by health insurance company bean counters for shareholders. The social costs of that policy would be beyond staggering.

Returning then to the Hacker plan:

Hacker’s plan works on a few basic principles. First, no one loses what they already have. You like your current insurance? Keep it, unless your employer kicks you off. Second, a new group market is created (the Health Care for America market, henceforth HCA), where insurers can compete for the business of individuals and employers (who can buy their employees in for 6 percent of payroll). Third, the group market contains a strong public insurer modeled on Medicare, creating competition between private insurance companies and the public offering. The hope is that the public insurer, which will not need to turn a profit and will be free of some of the perversities of private insurance, will prove the most cost-effective and attractive option, leading individuals and businesses alike to gravitate toward it. Over time, it would evolve into something approaching a single-payer system.

The HCA however is created to compete, as Klein says, with the private market and the plan assumes greater and greater buy in to the HCA absent any push back or media manipulation/messaging from the private insurance companies (remember 1993/1994 any Americans?). It would be something like a 2-tier structure as the private system would increasingly look, one imagines, into the insuring of healthier individuals, wealthier individuals and perhaps therapeudic practices (biotech, elective surgery, etc.). That would leave the HCA with the older, sicker populations, its care costs increasing and caps then perhaps put on available care not to mention the possibility of worse care (than the upper tier system). Though that is mitigated perhaps by the fact that 47 million already have no insurance and so many go to emergency rooms for care. So even reduced care seems a major step up for these folks.

But politically it will require depending on how this election goes at least 5-6 I would bet Republicans crossing-over in support. In fact it already is clear it is so politically sensitive Obama and Clinton have both dropped the ability of the HCA to cap spending, meaning the plans (both of them, mandate or no) would likely go way over budget. War or no war in Iraq, this is not good.

Which is where Wyden’s plan comes in–the I favor but sadly no presidential candidate is currently supporting–because he has 12 senators from both parties already on board. Including six Republicans.

Wyden’s plan:

Wyden’s plan differs from Hacker’s in two key ways. First, it lacks a public insurer, meaning that there won’t be public-private competition. But it compensates for that absence with much more radical system integration…Wyden’s plan, by contrast, does away with employer health coverage almost entirely. Rather than encouraging employers to transition to a single group market, as Hacker’s does, Wyden’s forces them to redirect all the money they were spending on employee insurance into paychecks. At the same time, it creates “Health Help Agencies,” one in each state, which act much like Hacker’s group market — they’re regulated structures where various insurers compete for business. No cherry-picking, no high premiums or denials of coverage for pre-existing conditions. Everyone pays the same price, but everyone has to buy insurance that’s at least as comprehensive as the current Blue Cross-Blue Shield Standard Plan. There are subsidies for those with low incomes, and penalties for those who don’t buy in. Medicare still exists for the elderly.

But here is politically where Klein points out we could be back to the past:

But where the basics of Hacker’s structure have a reformist political logic, Wyden’s risks running into the same fears that detonated the efforts in 1994. By blowing up the employer-based system, Wyden’s risks triggering the natural status quo bias of voters and insurers. In Hacker’s plan, the majority of the country sees no change unless they volunteer for it. With Wyden’s, the majority needs to buy new insurance. The question is whether Wyden’s plan can compensate for that political risk by attracting more support from stakeholders — employers who no longer want to run health-care businesses on the side and insured individuals worried about losing what they have. Also, to realize cost containment, Wyden’s state agencies would need to define, which is to say, regulate, qualified plans — a sensible policy that led the insurance industry to oppose a similar idea under a different name when Clinton proposed managed competition in 1993.

Published in: on May 7, 2008 at 4:23 pm  Leave a Comment  
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McCain’s Health Care Proposal

You can read the speech he gave and see his plan here from his website.

For a positive response to the plan, here from Matthew. For an opposite view, here, from Jonathan Cohn in the New Republic.

The center of McCain’s proposal is a $5,000 tax credit to be used for purchasing insurance. As a trade off, he will stop tax credit to businesses that give employees health care. Now I’m on record as favoring an end to the employer based US-system, but this I don’t think is the way to go about it.

The main arguing point politically for McCain with this plan is that it won’t bring in big government paternalistic liberalism, which is what the Democrats will achieve (so he argues).

McCain’s plan, conversely, touts creating a market, innovation in the field of health care, citizens being able to choose for themselves.

Here’s a problem with that outlook:

A big problem with this scheme, as critics like me pointed out, was that it wouldn’t do much for people who were already sick. Insurance companies generally won’t offer coverage directly to people with “pre-existing conditions,” since they represent such bad financial risks. (It turns out people with medical problems need medical care!) So buying insurance on their own really isn’t an option.

$5,000 won’t get you much if you can’t buy insurance because of pre-existing conditions and no government regulation of the industry and you have health costs of say $35,000. So to deal with that issue, McCain has the following proposal:

In a speech at a Florida cancer hospital, McCain acknowledged that people with pre-existing conditions can’t always buy insurance on their own. But, he says, that doesn’t mean these people will be left to twist in the wind. Instead, McCain is offering people like [Elizabeth] Edwards what he calls a “Guaranteed Access Plan.” But unlike all those awful big-government entitlements the Democrats are promising–you know, the ones that (supposedly) make you wait in long lines and cut off access to high-technology treatments–McCain says his plan will let the states handle the problem by working hand-in-hand with private insurers to offer insurance for people with pre-existing conditions.

Cohn writes:

It will be the best of both worlds, McCain promises: Affordable, available insurance, but through private carriers and without the heavy hand of Washington.It all sounds very lovely–unless you know something about health care policy, in which case it sounds absolutely preposterous.

And why is that exactly (bold in original)?

More than 30 states already have programs almost exactly like the one McCain just sketched out. They are called “high risk pools,” and the idea is pretty straightforward: Private insurers agree to sell policies directly to individuals, even those with pre-existing medical conditions, as long as the state helps to subsidize the cost.

But the whole reason conservatives like McCain prefer this approach to liberal schemes for universal coverage is that it involves minimal government regulation. As a result, private insurers have enormous leeway in dictating the terms of coverage. And one place they use that leeway is by setting high prices. A few years ago, a Commonwealth Fund study found that, on average, state high-risk pools offered coverage that was two-thirds more expensive than regularly priced coverage. In some states, the high-risk coverage was actually twice as high as regular coverage.

At those prices, you might think the coverage was spectacular. Not so. While private insurers in high-risk pools are willing to accept people with pre-existing conditions, they’re not generally willing to cover expenses related to those pre-existing conditions–at least not right away. Nearly all the plans surveyed had waiting periods of between six months and a year, during which the insurers would not cover care for prior medical problems.

Read the rest where Cohn takes the case of Elizabeth Edwards (wife of former candidate John Edwards) who has cancer. Her $5,000 tax credit will go a long way to paying her [low end estimate] $14,000/year to [high end] $100,000/year medical care. Of course she’s really rich, so she can get whatever. But for those who aren’t, then what happens?

Not to mention that McCain’s budgetary proposals will massively increase the deficit. Like every Republican since Reagan he will increase the federal budgetary deficit. Reagan, George HW Bush, George W Bush. All of them. Government will massively grow (particularly the national security state/defense industry and national surveillance state/industry) and continue to be as incompetent and not really much in return as the current Republican administration. At least on domestic issues.

I know the Democrats plan will come with increased costs. Their projections are always the best of all possible worlds scenarios and with any of these things (conservatives correct here) it will always be more complicated and expensive than imagined.

But is McCain’s plan really a workable alternative? Really? How long will the US continue to have the highest cost/person of health care and the worst coverage in the post-industrial world? This is massively hampering US economic competition. How is this not an outrage? Oh yeah, there’s an angry black preacher around there’s far more important–I forgot.

Published in: on April 30, 2008 at 9:18 am  Leave a Comment  
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E. Klein on (Sens) Wyden-Bennett Health Care Proposal

This is interesting.

Wyden (D-OR) and Bennett (R-UT).

Very radical middle-ish sounding:

Our employer-based health system is a costly mistake, the outgrowth of World War II-era wage and price controls and tax breaks that let newly flush employers shield their profits in benefits and escape taxation on health spending. Even today, employer spending on health care is tax deductible, while individual spending is not. It’s terrifically distorting, locking individuals into jobs they don’t want and stifling entrepreneurship, burdening corporations with duties they shouldn’t assume, and vastly increasing their power over employees. General Motors, after all, is a car company. They make cars. Who decided it should be in the health-care business, too? And if their employee decides to set off and make a better car, do we really want his plans foiled because he can’t interrupt his daughter’s dental care?

Rather than patching up the employer-based system and offering alternatives that individuals would maybe migrate toward, as both Clinton’s and Obama’s plans do, Wyden-Bennett end the employer-based system. They force employers to account for every dime and dollar they spend on employee health care and, the year after the bill’s passage, redirect that cash into employee paychecks. So if your employer is spending $7,000 a year for your health insurance, your paycheck gets a $7,000 boost as soon as their bill passes. You have the money they spent on your health care, but you are no longer dependent on them for that health care.

Under the Wyden-Bennett system, health dollars would be controlled by the individual (a long-time conservative goal) and used within a restructured, heavily regulated, totally universal, insurance marketplace (a longtime liberal goal). Each state would create Health Help Agencies, who would provide easy access to insurance products, along with information, guidance, and advice on how to choose. Insurers would have to meet a minimum standard for comprehensiveness (equivalent to the standard Blue Cross/Blue Shield plan currently offered to members of Congress), and they could not discriminate based on pre-existing conditions, occupation, genetic information, gender or age. Nor could they deny insurance to those who ask for it. In return, every American would have to buy health insurance, and there would be hefty subsidies for those further down the income ladder.

Published in: on February 16, 2008 at 1:23 pm  Leave a Comment  
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