The Reading Blog

Hillary Clinton said in her rousing August 26, 2008 speech at the Democratic National Convention, “… I can’t wait to watch Barack Obama sign a health care plan into law that covers every single American.” In reality, if, when, and what kind of plan will be signed remains the work of much speculation and hope. In my view, the current Obama proposal is a middle-of-the-road political campaign sketch designed to appease various views without ruffling anyone’s feathers too much, on either side of center. Even worse, the McCain plan is a typical Republication under-funded, voucher-like approach based on either an ignorant understanding of the real cost of health care in the U.S. or, more likely, a purposeful disregard of this reality and the lives of middle-class and poor working Americans.

For more thoughtful analysis of these plans, well beyond what you will find in most popular media treatments, check out the New England Journal of Medicine which is giving free full-text access to parts of its August 21, 2008 issue, including a thoughtful and highly readable article by Jonathan Oberlander, Ph.D., “Election 2008: The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform” and a videotaped debate among 13 panelists (a mix of physicians, academics, and leaders from business, insurance, and politics), “Shattuck Lecture: Health of the Nation — Coverage for All Americans.”

In Oberlander’s article criticisms of McCain and Obama’s plans include:

… How the McCain plan would affect costs and coverage is uncertain. Nobody knows how effective repealing the tax exclusion would be in controlling costs, but if it turns out not to be a magic bullet, the plan lacks other mechanisms for reliably slowing spending. Prevention, better care for chronic conditions, and enhanced competition represent aspirations rather than concrete policies for controlling costs. In addition, most uninsured Americans would probably remain uninsured under the McCain plan. .. Moreover, some employers, particularly smaller businesses, might stop offering insurance if the tax benefits of employer-sponsored insurance were eliminated. As a result, some currently insured workers could lose coverage. Perhaps the most serious problem with McCain’s plan is its reliance on the individual insurance market. Individual insurance policies are administratively expensive, typically involve medical underwriting so that sick persons and those with preexisting conditions are charged higher premiums (premiums also increase with age) or are denied coverage altogether, and generally offer less comprehensive benefits than employer-sponsored insurance.

The Obama plan’s precise impact on coverage is impossible to gauge. If the payroll tax is set low, many businesses would choose to pay it rather than offer coverage, and enrollment in a new national health plan could be substantial. The capacity of the Obama plan to expand insurance coverage depends on the scope of subsidies, premium prices, and the effectiveness of automatic enrollment or other participation-boosting policies, but details of those policies are not clear. Since the plan lacks an individual mandate for adults (coverage is mandated for children), it would not cover all the uninsured and therefore would provide universal access to insurance rather than universal coverage. However, most Americans without insurance would gain coverage through the new public and private insurance options, and Obama has not ruled out adopting an individual mandate in the future if the plan does not produce universal coverage.  Although the Obama plan would substantially expand access to insurance, it lacks reliable cost-control mechanisms and a viable financing source… The new national health plan could control costs, but its effectiveness in slowing spending would depend on its enrollment and the political willingness to restrain provider payments… if savings from prevention, disease management, and electronic medical records are not realized … then the Obama plan would need substantial additional revenues to fund expanded coverage.

Here are what I consider the most telling quotes from the text highlights of the debate (which was held way back in May 10, 2008 and is still very current),

• Arthur Caplan (Professor of Bioethics at the University of Pennsylvania, Philadelphia, PA): [The average physician's perspective is this:] I went to medical school. I’m loaded with debt. I’ve got an office full of people pushing paperwork every day. I don’t have time to talk to anybody. No one in Washington seems to care what I think. I can’t function this way. I don’t get reimbursed enough.
• Sara Rosenbaum (Professor of Health Law and Policy at George Washington University): [Access to care is] the most basic ethical issue of all. But it is a national decision on our part. It’s not the federal decision; it’s not the state decision; it is a national social decision. And we’ve been very bad about this.
• Jonathan Oberlander (Associate Professor of Social Medicine and Health Policy and Administration at the University of North Carolina, Chapel Hill): “The price tag for universal coverage really is not that much. If you talk about adding the uninsured to the existing system, you’re talking about roughly $100 billion a year. We already spend over $2 trillion, so it’s a mark-up but not much. When we cut taxes in 2001 and 2003, we found the money to do that. When we passed the Medicare Prescription Drug Benefit in 2003, we found the money to do that. When we went to war in Iraq, we found the money to do that. So this is a question of priorities. And the uninsured are not a political priority.”
• Susan Dentzer (Editor-in-Chief of Health Affairs, Bethesda, MD): “All [the presidential candidates' health] plans have a substantial element of unreality to them. Part of it is either Democratic or Republican holy writ that is being recycled from past debates. Part of it is fantasy based on a lack of understanding about how things really work now. We will have to wait till after the election — see how things settle out. And then engage in a realistic discussion about how to pick this up together.”
• Robert Galvin (Director of Global Health Care at General Electric, Fairfield, CT): “I think business is as willing to get out of what it’s doing now as it’s been since I remember. Even more than the early ’90s, simply because the costs continue to compound. So unless the Congress can work together on access and cost at the same time, it’s going to be difficult to sway the business community into believing what’s on the other side is not going to be worse than [what we have] today.”
• Charles Baker (President and Executive Officer of Harvard Pilgrim Health Care, Wellesley, MA): “[The presidential candidates' health plans are] political bromide — put out there so that if somebody says, “Do you have a position on health care coverage?” the answer can be yes. [This applies to] the whole debate about health care in the U.S. for the past 20 or 30 years, with the possible exception of the Medicare Modernization Act, where, whether you like it or not, the president basically said, “I’m going to stake my presidency on this, and it will happen.” And as a result, it did. That’s what you need a president to do if you’re going to get the coverage question resolved.”