Presidential Candidates’ Healthcare Proposals Comparative Analysis

This post presents a small part of the Presidential Candidates' Healthcare Proposals Comparative Analysis, which is still in development. After studying the details of the candidates' proposals, it seems that the main issues relate to these two questions:

1. Should all citizens have healthcare coverage (universal healthcare)? If so, what's the best way to do it?
2. Should healthcare value be improved? If so, how?

Following is an introduction to answering the first question.

To help answer this question, key points are presented followed a commentary and brief overview of the candidates' proposals. In my next post, I will give the details of their proposals, along with comments.

Universal Healthcare: Key Points

The case for universal coverage based on the philosophy that it is shameful for our wealthy nation to have approximately 47 million uninsured plus 16 million people underinsured, a number that's been growing constantly, along with the rising healthcare costs [reference]. Some argue that everyone in our nation should be covered since it is our moral responsibility, i.e., it's about communal spirit. And some claim that having a healthy, well cared-for population is a strategic imperative since you can't have a strong nation with a large percent of people at risk for serious illness and death due to lack of access to good, affordable care. That means, to the extent possible, it is in our country's vital interest to help our people lead longer, healthier, and more productive lives.

Of course, some argue that it is not their responsibility to sacrifice their hard-earned money for the well-being of others. These folks tend to be young, healthy or wealthy and resent having to pay more in taxes for publicly funded healthcare programs just because others have done irresponsible things in their lives that have made them sick or unable to afford good care. In other words, they don't deserve the care they need because they were not responsible and failed to make wise decisions. In addition, some opposed to universal coverage justify their position by claiming that the uninsured just don't want insurance, that the American system relies primarily on private enterprise to support health care, and that it's only the liberals and the urban poor who want a stronger public sector in health care. To help make sense of these arguments, consider the following commentary.

Universal Healthcare: Commentary

It is certainly understandable how young and healthy Americans do not want their tax monies going to help pay for the care of an older person with chronic illness. This kind of self-centered mind set is promoted in our culture. People in most other countries, where universal coverage is the norm, are willing to pay more in taxes to cover their needy. It's a cultural and moral issue, of which many Americans have been conditioned to think in terms of "me" rather than "we." Nevertheless, there is something to be said about personal responsibility.

To be responsible, people ought to take good care of their health by, for example:

• Eating foods lower in fat and carbohydrates, not smoke tobacco, avoid drinking much alcohol and using dangerous drugs, breath clean fresh air, stay out of the sun, exercise, etc.
• Earning good money, invest it wisely and save in order to afford treatment should they someday have a catastrophic or chronic condition.
• Rejecting short-term pleasures that have a potential negative health consequence.
• Going to the doctor, dentist, therapist, etc. only when necessary and selecting providers and treatments that are the most cost-effective.

And, it is only sensible that our culture, government, and economic system more likely that our citizens do such responsible things by making radical changes, such as:

• Making junk food more expensive than high-quality food
• Making tobacco and alcohol extremely expensive, while discouraging advertising to young people
• Putting businesses that blatantly pollute our air and waters out of business
• Down-playing the vanity of a sun tan
• Stopping the use of TV as the opiate of the masses, which creates so many "couch-potatoes," and start promoting more physical activity
• Rewarding healthcare providers for delivering high-value (cost-effective) care and preventive services, and insurers for offering high-value policies, as well as enabling consumers to select them through robust transparency of quality and cost
• Being role models of responsible money management, such as balancing the Federal budget rather than pushing incredible debt onto our children
• Making wise investing something that anyone can do rather than making the system so complicated and full of underhanded practices that it's so easy to get ripped off and make poor financial decisions
• Encouraging business to focus on long-term societal benefits rather than short-term investor returns
• Increasing the incomes of the working poor, so they have a chance to save for the future and purchase health foods, etc.
• "Leveling the playing field" so the disparity between the haves and have-nots aren't so drastic (the top 5 percent currently have more wealth than the remaining 95 percent of the population combined)
• Linking profit to value for the patient/consumer
• Putting at least some of the money currently being spent on political pork (estimated to be over $50 billion per year) and war (now about $500 billion and expected to go to $2 trillion) into improving our healthcare system.

Unfortunately, our nation often does just the opposite, so it's no surprise our citizens are often irresponsible. Under these destructive forces, does it really make sense to punish ill people for not taking good enough care of themselves? For more, see: Are you worthy of health insurance and high-value care? and Three stories about the dilemma modern consumers face in this era of "personal responsibility"

Also consider the myths--recently disputed by the Centers for Disease Control and Prevention (CDC)--that may affect one's point of view (quoted from New CDC Report: The Nail in the Coffin for Health Care Myths).

Myth: If people don't have health insurance or get medical care, it's because they don't want it.

Reality: Actually, the big issue with access is cost. According to the CDC report, more than 40 million Americans—almost one in five Americans over the age of 18—have foregone one of the following in the past year because they couldn't afford it: medical care, prescription medicines, mental health care, dental care, or eyeglasses.
It's not that uninsured people don't understand the value of coverage. Last year a study from the Urban Institute found that less than 3 percent of uninsured adults and children have never had insurance or report having no need for insurance. That same report also found that the high cost of coverage alone explained over 50 percent of those cases where people are uninsured

And even when the uninsured cite job-related difficulties as the reason why they can't access employer sponsored coverage, the problem isn't just that they can't get it through work—it's also that they can't afford individual policies. (Individual policies are much more expensive than group policies, and in many states private insurers can charge individuals astronomical premiums if individuals have any "pre-existing conditions.) According to the Urban Institute, for 79 percent of adults and 74 percent of children who are uninsured because of job-related problems, the high cost of individual insurance is a major problem.

Myth: The American system relies mostly, if not exclusively, on private enterprise to support health care.

Reality: Yes and no. While the U.S. does have the biggest private sector share of health expenditures in the world, making up 55 percent of our funding, personal health care expenditures (i.e. spending on actual patient care) is mostly public. The CDC reports that in 2005 the federal government and state and local governments combined paid 45 percent of personal health care expenditures; private insurers only paid 36 percent, with 15 percent coming from out-of-pocket payments. …

There's also a bigger public sector coverage presence than many would like to admit. Though two-thirds of insurance policyholders have private coverage, a Census Bureau report from earlier this year noted that more than one quarter of Americans (about 27 percent) are covered by government insurance. The [current] American model is much more of a private-public mix…

Myth: East coast liberals and the urban poor are the only ones who want a stronger public sector in health care.

Reality: Health care reform is often stigmatized as being something that only socialist, bleeding hearts dream of...But in fact, one particular area that could greatly benefit from a more proactive public sector is Middle America.

The CDC report notes that 4 percent of counties across the nation have no physicians. None. And more than 90 percent of these physician-less counties are non-metropolitan, i.e. do not contain a town of at least 10,000 people. In fact, across the nation only 9 percent of all of the nonfederal patient care physicians in the U.S. are located in these rural counties.

These sparsely populated locales are pretty much where you'd expect them to be: the Plains states and the Southwest (think Texas, the Dakotas, Oklahoma, Alaska)—home to many good old fashioned middle Americans. Initiatives to connect patients in these regions with physicians have come from the government, not the private sector...
[Both liberal and] conservative folks across the nation could benefit from a revitalized public sector [that makes] care accessible to regions where the medical market is non-existent.

Another report outlines questions American should consider when evaluating healthcare reform proposals. It contrasts proposals built around these three distinct philosophies, which assesses proposals "based not only on their ability to achieve universal coverage, but also on their potential to move the nation's health care system toward high performance …

1. Tax incentives for individual market insurance. Proposals that rely primarily on individuals' responsibility for obtaining coverage, with tax incentives to subsidize purchase of insurance in the individual insurance market.
2. Mixed private–public group insurance with shared responsibility for financing. Proposals that build on our current mixed private–public system of health insurance with shared responsibility for financing coverage by government, employers, and households.
3. Public insurance. Proposals that would cover nearly all Americans under public insurance programs, such as Medicare, with everyone covered through the same public system.

…both the mixed private–public group insurance and the public insurance reform proposals have the greater potential to move the health care system toward high performance. Both approaches have the potential to provide everyone with comprehensive and affordable health insurance, achieve greater equity in access to care, realize efficiencies and cost savings in the provision of coverage and delivery of care, and redirect incentives to improve quality. From a pragmatic perspective, however, the mixed private–public approach would cause far less dislocation by allowing the more than 160 million people who now have employer-based health coverage to retain it, instead of asking them to enroll in a new program. This approach would build on the best features of our current system while addressing its most serious shortcomings: gaps in coverage and the absence of the incentives, organization, and infrastructure required for a high performance health system.

…Extending health insurance coverage to people who currently lack it is a necessary, but not sufficient, condition for achieving high performance. The way in which a universal coverage system is designed will have a deep impact on its ability to make sustainable and systematic improvements in access to care, equity, quality of care, efficiency, and cost control. With these goals in mind, the following are some key principles policymakers and the public should consider in developing or evaluating health reform proposals:

Access to Care

• Provides equitable and comprehensive insurance for all.
• Insures the population in a way that leads to full and equitable participation.
• Provides a minimum, standard benefit floor for essential coverage with financial protection.
• Premiums, deductibles, and out-of-pocket costs are affordable relative to family income.
• Coverage is automatic and stable with seamless transitions to maintain enrollment.
• Provides a choice of health plans or care systems.

Quality, Efficiency, and Cost Control

• Health risks are pooled across broad groups and over lifespans; insurance practices designed to avoid poor health risks are eliminated.
• Fosters efficiency by reducing complexity for patients and providers, and reducing transaction and administrative costs as a share of premiums.
• Works to improve health care quality and efficiency through administrative reforms, provider profiling and network design, utilization management, pay-for-performance payment models, and structures that encourage adherence to clinical guidelines.
• Minimizes dislocation; people can maintain current coverage if desired.
• Simple to administer.
• Has the potential to lower overall health care cost growth.

Financing

• Financial commitment to achieve these principles.
• Financing should be adequate and fair, based on ability to pay, and is a shared responsibility of federal and state governments, employers, individual households, and other stakeholders.

…Conclusion
Ultimately, we must move the health care system to high performance using goals and properly aligned incentives that orient all participants in the same direction: toward improved access, quality, equity, and efficiency. The most important feature of any health insurance reform proposal is whether it can succeed in providing health insurance and access to care to all. In addition, proposals should be examined for their ability to produce better access, higher quality, and greater efficiency. Whenever possible, we must seek synergy between coverage expansion and reform that will move the U.S. to a high performance health system.

Achieving universal coverage will require engaging everyone in a debate on values, our commitment to a healthy and productive life for all, and the merits of different strategies for achieving improved coverage and better performance from our health system. …Serious reform will require broad consensus and a significant financial investment by federal and state governments, employers, households, and other stakeholders. A shared responsibility among all stakeholders will be needed to achieve the goals of reform in a way that is effective and fair.

Brief Overview of the Candidates' Proposals

All the Democrats propose universal healthcare (coverage for all Americans). Only Kucinich supports HR 676, which is a single-payer, "Medicare for All" plan that gives everyone comprehensive coverage. Gravel also proposes a single-payer solution, but through use of federally funded vouchers. All the other Democrats propose a public Federal Employees Health Benefits Program (FEHBP) type program and/or Medicare, Medicaid, SCHIP, which are supported by subsidies (e.g., through tax credits or vouchers) to low income persons.

Republicans, on the other hand, do not propose new public programs, the expansion of existing public programs, nor universal coverage. Instead, they all propose market-based private insurance solutions through tax deduction/credit subsidies to lower insurance premiums and deduct medical expenses from the taxes of lower income persons. Other strategies include increasing competition, tort reform, and payment changes to providers.

The strategies related to universal coverage, which are discussed below, include:

• New and expanded public programs
• Allowing private insurance
• Mandates for individuals and businesses
• Insurance pooling (community ratings)
• Changes in Private Insurance
• Subsidies/tax credits/deductions for individuals and businesses
• Funding it through taxes and savings

In my next post, I discuss whether government can be trusted to run a single-payer system.