A GOP Debate Primer: Healthcare In The 10 Candidates' Own Words

This political season is unusual in terms of the divergence of views held by the field of 17 GOP candidates. Where they are all unified is in a universal call for the repeal of The Affordable Care Act (ACA), more commonly known as Obamacare. However their moment of unity is fleeting as they diverge again with what should replace it. Here I wanted to take a look at what Trumpcare would look versus Rubiocare or Cruzcare. Our research revealed that there is a general lack of framework and sometimes consistency among the candidates based on their past statements. Of course it’s very early in the campaign season, and, based on some of the information gathered here, it’s certain that policies and opinions will evolve as the field is whittled down. In any event, with two doctors on the stage (Rand Paul and Ben Carson are medical doctors), it will be interesting to see how prominently healthcare plays as a topic for the debates, and how much further the candidates will clarify their positions vis-a-vis Obamacare.

Here are three bullets from each of the 10 debating candidate’s healthcare positions presented in order of their latest polling results:

Donald Trump | Poll: 26%

Donald Trump (Photographer: Victor J. Blue/Bloomberg)

1. Trump once spoke of a single-payer system in his book The America We Deserve, but has recently stated his support for a market-based approach to healthcare reform. He has continued to state that he wants to “take care of everybody.”
2. Trump plans to reduce health insurance costs by increasing competition and allowing insurance companies to compete across state borders. Trump also plans to maintain strong capital controls on these companies to act as a buffer for “catastrophic events.” He has stated that he is open to the idea of government assistance in paying for healthcare.
3. To provide healthcare for low-income Americans, Trump intends to work out “a very, very smart plan with hospitals.”

Jeb Bush | Poll: 15%

Jeb Bush (AP Photo/Jim Cole)

1. Bush has advocated for healthcare reform that involves state-administered subsidies. This system, unlike the Affordable Care Act, would not have mandates and focuses on giving decision-making power to consumers.
2. Bush wants a catastrophic coverage system where the government provides relief for those whose hardship goes beyond their means of paying for it. These plans would cover significant injury more cheaply than comprehensive policies, but would not cover routine medical appointments.
3. During his term as Governor of Florida, Bush changed Florida’s Medicaid program from a defined benefit plan (where states define what medical procedures to pay for) to a defined contribution plan (where states cap the amount they will spend on each recipient).

Scott Walker | Poll: 9%

Scott Walker (AP Photo/Jim Cole)

1. Walker refused to expand Medicaid in exchange for federal money, and instead has proposed a hybrid approach that uses the federal poverty level as the threshold for Medicaid eligibility and provides private-subsidized insurance to those between 100% and 200% of the poverty line.
2. Walker signed a letter asking the Federal government to ease healthcare mandates so that states could have more leeway in crafting healthcare policy. The letter specifically objected to the Maintenance of Effort provisions of the Affordable Care Act, which required states to maintain Medicaid eligibility levels until 2014.
3. Walker has voiced doubts about the ability of the Federal Government to fund the expansions of Medicaid that have occurred in other states.

Mike Huckabee | Poll: 7%

Mike Huckabee (AP Photo)

1. Huckabee has stated that a healthcare system that espouses prevention of disease rather than treatment of it would save lives and save costs. Huckabee wants to reduce costs by preventing expensive chronic conditions.
2. Huckabee has often talked about the problem of obesity and unhealthy lifestyles as a cause of increased healthcare costs, and has even written a book about weight loss titled Quit Digging Your Grave With A Knife and Fork.
3. As an alternative to the Obamacare/ACA, Huckabee wants individual states to test their own healthcare reforms. He also especially opposes the individual mandate provision of the Affordable Care Act.

Ben Carson | Poll: 7%

Ben Carson (AP Photo/Jim Cole)

1. Carson has stated that Obamacare/ACA must be replaced before it is repealed.
2. Carson advocates for Health Savings Accounts (HSAs) as a means to replace Obamacare/ACA and cut healthcare costs. Individuals would have savings accounts to finance their healthcare expenditures. For those unable to contribute to their HSAs, he proposes that federal funding be used to sustain their accounts ($2,000/year) in order to provide them with greater freedom and control over their healthcare.
3. He has stated that his HSA plan would reduce national healthcare spending by 80% down to $630 billion. Carson says his plan would eliminate Medicare and Medicaid.

Ted Cruz | Poll: 6%

Ted Cruz (AP Photo/Jim Cole)

1. Cruz has sponsored the Health Care Choices Act. This act would give individuals the opportunity to purchase health insurance across state borders, allowing for market forces to make competitive options available to citizens.
2. Cruz views the Medicare Part D Drug Program as unconstitutional.
3. Cruz has proposed raising the eligibility age for seniors for Medicare when asked about the rising costs of the program.

Marco Rubio | Poll: 5%

Marco Rubio (AP Photo)

1. Rubio has proposed a healthcare plan that he says could replace the Obamacare/ACA with a system of tax credits, federal coverage for patients with pre-existing conditions and reforms to Medicare and Medicaid.
2. Rubio was one of the key supporters of the effort in 2013 to try to defund Obamacare by causing a government shutdown. According to Rubio, “this is the only chance and the last chance we have” to repeal Obamacare.
3. Ironically, Rubio is actually enrolled in the exchange system. His spokesperson has said, “Senator Rubio spent time looking at all the options and decided to enroll through the D.C. exchange for coverage for him and his family.”

Rand Paul | Poll: 5%

Rand Paul (AP Photo/Jim Cole)

1.  Paul is on the record having said, “With regard to the idea of whether you have a right to healthcare, you have to realize what that implies. It’s not an abstraction. I’m a physician. That means you have a right to come to my house and conscript me. It means you believe in slavery.”
2. Paul said “I was not a member of the United States Senate during the 111th Congress, but if I had been I would have voted against Obamacare. As your President, one of my first acts would be to repeal the abomination that is Obamacare.”
3. Paul has said if Obamacare was repealed, “We could try freedom for a while. We had it for a long time. That’s where you sell something and I agree to buy it because I like it.”

Chris Christie | Poll: 3%

Chris Christie (AP Photo/Jim Cole)

1.  Christie has criticized Obamacare/ACA, calling for its repeal, but Christie expanded Medicaid in New Jersey, citing that he felt that it was best for the state.
2. Christie proposes giving individual states a fixed amount of Medicaid funds indexed to the number of Medicaid enrollees. As a result, states would have the freedom to tailor their Medicaid programs to their citizens.
3. Christie has stated that to contain Medicare spending growth, he will consider means testing. Simply put, those who can afford to pay for health benefits will, while those who are unable to will not.

John Kasich | Poll: 3%

John Kasich (AP Photo/Jim Cole, File)

1.  Kasich has stated, “I’m not for Obamacare. I have expanded Medicaid, because I wanted to bring Ohio dollars back to Ohio.  We’ve been able to apply it to bring significant change, and our ultimate goal is that so all of these people who have been hurt can be in a position to get on their feet and move forward.”
2. Kasich advocates for a $776 billion tax cut plan that he has stated “will help people afford healthcare.”
3. Kasich also defended his stance on expanding Medicaid by saying “The last Republican I can think of who expanded Medicaid was Ronald Reagan.”

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FACTBOX: Obama's ambitious healthcare plan

(Reuters) - President-elect Barack Obama has proposed an ambitious plan to reform U.S. healthcare and get insurance for at least some of the 47 million Americans who now lack it.

Following are some facts about his healthcare proposals:

-- A National Health Insurance Exchange to help people buy private insurance, act as a watchdog and create standards, supplemented in part by a tax on employers who do not provide coverage.

-- Offer small businesses a tax credit to help pay for employee health insurance.

-- Require healthcare for all children, and expansion of Medicaid, the federal-state health insurance plan for the poor and disabled, and the State Children's Health Insurance Program or SCHIP.

-- Allow children to stay on parents' health insurance through age 25.

-- $50 billion to be spent creating a cohesive system for electronic health records.

-- Stop insurers from denying coverage based on pre-existing conditions.

-- Require coverage of preventive services such as cancer screenings, and increase state and local preparedness for terrorist attacks and natural disasters.

-- Obama's health advisers have studied the idea of a "medical home" -- a primary care doctor who would help coordinate and oversee care -- as well as the possibility of paying doctors to spend time with patients on preventing disease and rewarding them for better outcomes.

-- Obama says he can reduce healthcare spending by 8 percent and save each taxpayer $2,500.

-- The Lewin Group, a consulting firm, forecasts the Obama proposal would raise federal spending by $1.17 trillion from 2010 through 2019.


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Barack Obama Health Care Plan Endorsements

"Why Obama's Health Plan Is Better" - Wall Street Journal

"Health Care Destruction" Paul Krugman - New York Times - Nobel Laureate in Economy

"McCain health care plan a dangerous idea" - Christian Science Monitor

"Obama Can Cure Health Care's Ills" - Forbes

"Obama’s health care plan is best solution" - Windsor Beacon

"John McCain's health care plan is worse for women" - Seattle Post-Intelligencer

"Obama's Healthcare Plan Insures More People Than McCain's, Study Says" - Medscape

"Benefits Execs Prefer Obama's Health-Care Plan" - Business Week

State Rep. Phyllis Mundy Wednesday hailed Democratic presidential candidate Barack Obama’s health care plan as the best, while calling Republican John McCain’s approach “fatally flawed.” - Times Leader

Report sides with Obama's healthcare plan" - UPI

"5 Democratic governors urge Obama health plan" - The Philadelphia Inquirer

"What Do Doctors Think Of McCain Vs. Obama Health Plans?" - Survey of 1,100 Doctors

The American Nurses Association Endorses Senator Barack Obama

Planned Parenthood - "Sen. Barack Obama stands for reproductive health"

"Report: Obama health care plan would reduce uninsured by 26.6 million, McCain's by 21 million" - Fox Indianapolis

"McCain's Radical Agenda" - New York Times

"Look before you leap into McCain's idea of health coverage" - The Ann Arbor News

"In fairness, whose plan is better? - When it comes to fixing our health care system, McCain got it half right, Obama got it more right" - Baltimore Sun

Massachusetts: Doctors oppose health plan

US doctors favour single payer system.

The Massachusetts healthcare programme widely seen as a test case for universal health coverage in the US faces mounting opposition from doctors who say the reform is failing.

More than 250 physicians in the state have signed an open letter warning that the healthcare plan, which was signed into law in April 2006 by Mitt Romney, the former Republican governor of Massachusetts, is “already proving fiscally unsustainable”.

The landmark programme, designed to provide uni­versal health insurance, requires all uninsured people to purchase private insurance or face a fine or tax penalty.

The doctors’ discontent with the plan, and their support for a single-payer system – whereby payments to healthcare providers would all be made by one administrative body like Britain’s National Health Service, rather than individual insurers – could send a strong signal to other states considering similar reform measures.

Healthcare is one of the main issues on the presidential campaign trail. Both candidates have called for radical reform of the $2,300bn (€1,477bn, £1,172bn ) healthcare system, although neither supports mandatory insurance payments.

In the letter, the Massachusetts doctors say the state-subsidised insurance offered to low-income families is too expensive and that “few can afford premiums for even the skimpiest coverage”. The doctors also warn that funding the plan in future will be hard because it deepened the state’s “dependence on private insurance, [so] can only add coverage by adding costs”.

The Massachusetts plan is an example of “the same reform being tried over and over”, according to Dr Rachel Nardin, assistant professor of neurology at Harvard Medical School, who wrote the letter. “This kind of incremental reform is very popular because it’s politically feasible: it allows the current stakeholders to stay in play,” she said. “But there are a lot reasons why it can’t work.”

A growing number of US doctors favour switching to a national healthcare plan. According to an earlier survey in the journal Annals of Internal Medicine, 59 per cent of doctors said they backed legislation to establish a national health insurance programme, a rise of 10 per cent from 2002.

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Massachusetts: Doctors shortage imperils healthcare pledge

Primary care doctors are in “critically short supply” in Massachusetts, a shortage that poses a threat to the state’s healthcare reform initiative and underscores a nationwide problem that could hinder efforts to enact universal healthcare.

According to a report by the Massachusetts Medical Society, an inadequate supply of primary care physicians and certain specialists, including oncologists and neurologists, puts in doubt the state’s “ability to efficiently handle the increased demand for health services”.

“If the trend continues it won’t matter if everyone has health insurance; there won’t be a doctor to go to,” said Dr Bruce Auerbach, the group’s president. “The workforce issue is at the core of our provision of healthcare.”

The healthcare plan, which was signed into law in April 2006 by Mitt Romney, the former Republican governor, has resulted in new healthcare coverage for more than 400,000 residents. As a result, the state has seen rising demand for primary healthcare services that cannot be met with the its supply of physicians.

Primary care doctors are those to whom patients turn with sore throats, sinus problems and sprained ankles. They also work on chronic care and preventative care, by helping patients maintain health with immunisations and cancer screenings.

The dearth of primary care doctors is a problem across the US, according to Jim King, president of the American Academy of Family Physicians. “Essentially, the situation in Massachusetts reflects the fact giving everyone a health insurance card will not guarantee access to care unless public policy also solves the problem of [the shortage of] primary care physicians,” he said.

The number of medical graduates opting for residencies in family practice, internal medicine and paediatrics dropped 7 per cent from 1995 to 2006, according to congressional testimony earlier this year from the Government Accountability Office.

Dr King said that today’s medical students were not choosing careers in primary care because it does pay enough and is not seen as a particularly desirable lifestyle. “They go through medical school and accumulate huge debt of $150,000-$200,000 and see that if they enter a speciality field, rather than family medicine, they can earn a lot more,” he said. ‘There is also the misconception that family physicians are always on call: no time for family.”

Bill Draycos, director in PwC’s health advisory practice, noted that many medical schools have increased enrolment and have added branch campuses to deal with the shortage. Several states, including Arizona and Florida, have opened new schools. “But we won’t see the benefit for another eight to 10 years,” he said.

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Father Sam Explains It All

An interesting evaluation of McCain's health plan from Time Blog followed by discussion:

I read his proposal in the American Academy of Actuaries magazine, Contingencies. It will not work, in my opinion, even if he could get a Democratic Congress to go along (it would not).

Most Americans with health insurance get it through an employer and those folks are relatively happy with it. Employers are not happy with it generally and would like to get away from providing it. The government allows companies to deduct health care expenses from income and does not count the cost of health benefits as income to the employee. In effect it is away of paying employees tax free income, as long as it goes to heath care. (Originally this was a way to work around the WWII freeze on ordinary wages.) McCain's proposal does way with this setup, making the heath care benefit taxable income. On average that is $12,000 per year for a family of four. If a family continues in an employer program it will pay an additional tax. If they are in the 25% bracket (say $75000 income) then they pay an additional $3000 in taxes. An individual in an employer plan with health benefits of about $6000 so will pay an additional $1500 in taxes.

McCain's proposal gives individuals a $2500 tax credit so the net for an individual is a tax credit of $1000. For a family with two persons filing, they get a tax credit of $5000, so get a net $2000 credit they can use to off set other taxes. (Actually it is not clear on this; maybe you do not get an offset.) So far is looks good for those who that already have health care through an employer. However, the costs are escalating faster than overall price inflation, so unless the tax credits are indexed to heath care costs, the advantage will disappear in a few years. While this aspect looks good now (for those who have and can continue with employer coverage), that may change without indexing. The proposal says nothing about indexing.

A family with no employer health care pays an average of more than $12000 per year for insurance because individual plans are more expensive (or go without and experience about the same out of pocket heath expenses on average with a lot more variance). They get the tax credit too, so a family gets a $5000 but it still costs them $7000 per year. This may bring coverage into reach for some families, but certainly not all.

Only about 60% of employers provide health care coverage. McCain's program removes the incentive for employers to provide it so I expect a lot of them will stop providing it. More Americans will be on their own, those with preexisting conditions will not get insurance. And it provides no incentive for employers to start covering employees. For small businesses, the situation is worse - only about 45% provide health benefits.

Another important aspect of McCain's plan is to deregulate health insurance. Now the states regulate it and provide consumer protection, solvency and other regulations. McCain says he will deregulate as "we have done over the last decade in banking." We see now how that turned out. It will be a huge mess.


I don't think McCain understands insurance or insurance regulation. This is just false: "Health insurance is simply a financial device that shifts around the apparent costs of the nation's overall health care bill among various payers." Above all, insurance is a mechanism for managing risk. It also provides for economy of scale too but the primary function is to reduce the risk to an individual or family of catastrophic heath care costs. It is a very serious problem and McCain's proposal ignores it. No other developed nation treats its citizens this way, forcing them to bear the risk of catastrophic heath care costs.

There is no reason to believe McCain's proposals will solve the problems of rising health costs or lack of coverage. Indeed, I think it will aggravate these serious problems.

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Obama camp hits rival's health care plan

After knocking John McCain as a deregulator of the banking system during the recent financial crisis, Barack Obama's campaign hit the Arizona senator Sunday for wanting to do the same to the health insurance industry.

"Nothing would be more precarious to Americans than losing their healthcare," Kansas Gov. Kathleen Sebelius said on a conference call with reporters.

Sebelius linked healthcare to the recent financial crisis throughout the call, and suggested that McCain's healthcare plan would lead to a similar crisis.

"As terrified as people are about the economic crisis that now faces this country, I don't think any situation is as personal as health care," Sebelius said. "John McCain would apply to the insurance industry what he did to the banking industry."

Sebelius said McCain would "dismantle state based regulation and tie the hands of those involved in consumer protection."

McCain senior policy adviser Doug Holtz-Eakin defended the Arizona senator's healthcare plan in a memo responding to Obama's attacks.

"John McCain believes that American families should be given more choices by allowing them to purchase policies across state lines," Holtz-Eakin wrote. "In a move derided by fact checking organizations including Fact Check, the Obama campaign used this as an opportunity to falsely accuse John McCain of deregulating health care markets akin to Wall Street."

Obama has stepped up his attacks on the issue in recent days, calling McCain's plan a "bait-and-switch" during a campaign stop yesterday in Virginia. Obama's running mate, Sen. Joe Biden, called the plan "the ultimate bridge to nowhere" during Thursday's vice presidential debate.

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Health Care Destruction - PAUL KRUGMAN

Sarah Palin ended her debate performance last Thursday with a slightly garbled quote from Ronald Reagan about how, if we aren’t vigilant, we’ll end up “telling our children and our children’s children” about the days when America was free. It was a revealing choice.

You see, when Reagan said this he wasn’t warning about Soviet aggression. He was warning against legislation that would guarantee health care for older Americans — the program now known as Medicare.

Conservative Republicans still hate Medicare, and would kill it if they could — in fact, they tried to gut it during the Clinton years (that’s what the 1995 shutdown of the government was all about). But so far they haven’t been able to pull that off.

So John McCain wants to destroy the health insurance of nonelderly Americans instead.

Most Americans under 65 currently get health insurance through their employers. That’s largely because the tax code favors such insurance: your employer’s contribution to insurance premiums isn’t considered taxable income, as long as the employer’s health plan follows certain rules. In particular, the same plan has to be available to all employees, regardless of the size of their paycheck or the state of their health.

This system does a fairly effective job of protecting those it reaches, but it leaves many Americans out in the cold. Workers whose employers don’t offer coverage are forced to seek individual health insurance, often in vain. For one thing, insurance companies offering “nongroup” coverage generally refuse to cover anyone with a pre-existing medical condition. And individual insurance is very expensive, because insurers spend large sums weeding out “high-risk” applicants — that is, anyone who seems likely to actually need the insurance.

So what should be done? Barack Obama offers incremental reform: regulation of insurers to prevent discrimination against the less healthy, subsidies to help lower-income families buy insurance, and public insurance plans that compete with the private sector. His plan falls short of universal coverage, but it would sharply reduce the number of uninsured.

Mr. McCain, on the other hand, wants to blow up the current system, by eliminating the tax break for employer-provided insurance. And he doesn’t offer a workable alternative.

Without the tax break, many employers would drop their current health plans. Several recent nonpartisan studies estimate that under the McCain plan around 20 million Americans currently covered by their employers would lose their health insurance.

As compensation, the McCain plan would give people a tax credit — $2,500 for an individual, $5,000 for a family — that could be used to buy health insurance in the individual market. At the same time, Mr. McCain would deregulate insurance, leaving insurance companies free to deny coverage to those with health problems — and his proposal for a “high-risk pool” for hard cases would provide little help.

So what would happen?

The good news, such as it is, is that more people would buy individual insurance. Indeed, the total number of uninsured Americans might decline marginally under the McCain plan — although many more Americans would be without insurance than under the Obama plan.

But the people gaining insurance would be those who need it least: relatively healthy Americans with high incomes. Why? Because insurance companies want to cover only healthy people, and even among the healthy only those able to pay a lot in addition to their tax credit would be able to afford coverage (remember, it’s a $5,000 credit, but the average family policy actually costs more than $12,000).

Meanwhile, the people losing insurance would be those who need it most: lower-income workers who wouldn’t be able to afford individual insurance even with the tax credit, and Americans with health problems whom insurance companies won’t cover.

And in the process of comforting the comfortable while afflicting the afflicted, the McCain plan would also lead to a huge, expensive increase in bureaucracy: insurers selling individual health plans spend 29 percent of the premiums they receive on administration, largely because they employ so many people to screen applicants. This compares with costs of 12 percent for group plans and just 3 percent for Medicare.

In short, the McCain plan makes no sense at all, unless you have faith that the magic of the marketplace can solve all problems. And Mr. McCain does: a much-quoted article published under his name declares that “Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.”

I agree: the McCain plan would do for health care what deregulation has done for banking. And I’m terrified.

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McCain health care plan a dangerous idea

The threat to the economy caused by the collapse of Wall Street has become the dominant issue of the presidential election. The credit crisis must be dealt with promptly. But the long-term strength of the nation's economy can't be separated from the drain caused by the cost, inefficiency and unfairness of what passes for America's health-care system.

Barack Obama and John McCain both have plans to change that system. Obama would retain the current employer-based system and expand on it by subsidizing coverage for those who can't afford insurance. His plan would not guarantee universal coverage and its cost is uncertain. But it would likely do more good than harm.

McCain would blow up the current system and ensure that fewer Americans are covered. He wants to eliminate the tax deduction employers get for providing health insurance. Instead, he would give tax credits to individuals and families to make it easier for them to purchase insurance on what he believes will be a new, bigger open market that will compete to lower health care costs. The credits would be $2,500 per individual and $5,000 per family.

There are more components to the McCain plan - portability of insurance from state to state, for example - but none would offset the enormous damage his on-your-own in a wide-open market approach would do.

Eliminating the employer tax deduction would make it more expensive to insure workers. Employers could lower wages to make up the difference, raise the amount employees pay to participate in the plan, or eliminate the benefit.

Lowering wages would make it harder to get and keep workers. Raising employee contributions would give healthier workers an incentive to opt out. That would leave companies with an older, sicker, more expensive pool of insured.

McCain imagines that people will form voluntary pools in churches, social clubs and other venues to negotiate for the best price. But people would be on their own, trying to sort between competing plans. Some of the plans would be good, some awful.

In the Sept. 16 issue of the journal Health Affairs, four experts dissected McCain's plan. They predict it would decrease the number of people insured through employers by 16 million to 28 million. If a large number of those who lose employer coverage buy private insurance and, thanks to the tax credits, a large number of people who now lack coverage buy it, the rolls of the uninsured could decrease by a few million, the experts say. But many people would buy bare-bones coverage, policies that typically have very high deductibles and are useful primarily for major medical problems.

Since the administrative costs for non-group insurance are higher than for group insurance, prices would be higher and coverage less generous, the experts said. As a result, people would pay more for less. McCain's plan would also override state laws that bar insurers from red-lining, selling cheap to the healthy and dear to those with prior conditions or a family history of disease. Insurers could also drop coverage for costly treatments now mandated by state laws.

McCain is willing to destroy the existing health-care system, which bad as it is, does provide excellent, albeit costly, care for almost all who have employer-based insurance. Instead, he would throw consumers on the mercy of a marketplace that he believes will fight for their business by offering high quality at lower prices and make health-care more affordable.

That's a plan that only a maverick who's strayed off the range and into a swamp would take.

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Presidential Candidates Present Their Healthcare Reform Plans in New England Journal of Medicine

With the nation's attention riveted on Wall Street, government bailouts, and housing foreclosures, another issue of prime concern to Americans in this election year has been shoved out of the spotlight: Sen. Barack Obama's and Sen. John McCain's positions on healthcare reform.

The New England Journal of Medicine invited both the Democratic and Republican candidates for president of the United States to outline their plans for healthcare reform, with commentary on each provided by observers from the opposite end of the political spectrum. Outlines of the candidates' plans and the critiques were published online September 24 and will appear in the October 9 (plan outlines) and October 16 (critiques) print issues of the journal.

There isn't much that the candidates agree on in other areas of public policy. But in side-by-side columns with color-coded headings — blue for Sen. Obama and red for Sen. McCain — the senators lay out their strategies for providing universal access to affordable, high-quality care.

However, their strategies outline fundamental philosophical differences, with Sen. Obama embracing a more public solution and Sen. McCain endorsing a more market-based approach.

The Obama Plan

Sen. Obama, who favors a mix of public and private participation, outlines 3 broad healthcare reform goals:

- Equal access to high-quality, affordable health care for all Americans.
- Elimination of wasteful spending, including "layers of bureaucracy that serve no purpose, duplicative tests and procedures that are performed because the right information is not readily available, and doctors providing unnecessary care for fear of being sued."
- Emphasis on disease prevention and health maintenance.

According to Sen. Obama, patients who like their insurance will be able to retain it with no changes, except for lower costs. Uninsured or underinsured patients would be offered a choice of affordable plans, and he calls for establishment of a national health-insurance exchange for small businesses or people without employment-based insurance; the plans would offer policies at rates similar to those offered through large companies, although Sen. Obama does not specify how this would be achieved.

"To promote competition among insurers, we will also give patients a new public-plan option, providing the same coverage that is offered to members of Congress and their families," the Democratic candidate writes.

Sen. Obama's plan also calls for:

- Mandatory acceptance of enrollees by insurers without regard to medical history.
- Tax credits for families to increase affordability.
- Expansion of Medicaid and the State Children's Health Insurance Program (S-CHIP) to cover all children without private coverage.

Sen. Obama says that the expanded programs will be paid through elimination of waste and through repeal of the Bush administration tax cuts for Americans with the highest incomes. He notes that he opposes taxes on employer-based health insurance.

Reimbursement, Medical Liability Changes

"We also need to change the way we reimburse for patient care," Sen. Obama writes. "We should start paying adequately for care coordination, case management, and innovative care-delivery models, such as team-based care and electronic communication. Doctors should be paid fairly by private insurers and by Medicare. Payment reform should improve patient outcomes and should lower overall costs by removing incentives for unnecessary care and rewarding the right care, provided at the right time, for the right reasons"

Sen. Obama states that his administration will offer incentives for physicians in training to enter primary care, and he emphasizes renewed support for biomedical research. He also proposes to reduce malpractice insurance burden through information systems, decision support technology, and patient-safety initiatives aimed at reducing medical errors.

"I will also support legislation dictating that if you practice care in line with your medical societies' recommendations, you cannot be sued," he writes.

"Too Audacious to Be Believed"

In an editorial critical of the Obama plan, Joseph R. Antos, PhD, a scholar in healthcare and retirement policy at the American Enterprise Institute, a conservative think-tank in Washington, DC, says that the Obama plan is "too audacious to be believed."

"The Obama plan offers a host of policy proposals that, in the main, address the symptoms but not the underlying disease that afflicts the health care system," Dr. Antos writes. "We surely could use some symptomatic relief. However, failing to address the perverse incentives that drive health care spending inexorably upward, making insurance unaffordable for millions and shaping (or misshaping) the practice of medicine, will leave us worse off than we are today."

The "perverse incentives" Dr. Antos refers to include a "play or pay" option, similar to that currently in place in Massachusetts, under which employers that do not provide health insurance coverage pay a per-worker surcharge that is used to finance a publicly funded healthcare system.

"A play-or-pay policy probably would not be effective in expanding employer-sponsored insurance," Dr. Antos writes. "Employers who already offer generous health benefits would not have to change their compensation structure. Other employers would choose to 'pay' rather than 'play' unless the new tax were more expensive than the cost of paying the mandated amount for insurance, which is politically implausible."

Dr. Antos also claims that the non–group insurance plans offered to uninsured families under Sen. Obama's plan must of necessity either offer a wide range of benefits and be costly or offer more narrow but less costly basic plans with high out-of-pocket costs.

"A generous plan requires premiums that would be unaffordable to many of the uninsured unless there was also a generous subsidy from taxpayers," he writes. "A more basic plan would have more affordable premiums, but beneficiaries would face higher out-of-pocket costs if they became seriously ill. Lower premiums and skimpier benefits are not what the Democratic political base thinks it has been offered."

The author is also critical of the Democrat's proposed health insurance exchange, saying that it would limit the market-based competition, and adds that Sen. Obama's plan to regulate health insurers more closely "substantially increases the risk of government failure and regulatory gridlock."

The McCain Plan

Sen. McCain favors a market-driven, privately funded approach to healthcare, although he too emphasizes basic tenets of reform, including:

- Access to high-quality care
- Choice of insurance coverage
- Affordability
- Portability

"But the road to reform does not lead through Washington and a hugely expensive, bureaucratic, government-controlled system," he writes.

Sen. McCain calls for moving Medicare toward a system that favors coordinated care and "higher quality care" for seniors, but does not specify how this would be accomplished.

The Arizona senator supports a greater emphasis on health maintenance, screening, prevention, and early intervention.

"We need to create a next generation of efforts to prevent chronic disease, early intervention programs, new treatment models, and public health infrastructure," he writes. "We need to use technology to share information on 'best practices' in health care so that every physician is up to date. We need to adopt new treatment programs and financial incentives to promote healthy habits among Americans with the most common conditions, such as diabetes and obesity, in order to improve their quality of life and reduce the cost of their treatment."

Tax Credits, Tort Reform

Sen. McCain's plan calls for dropping the exclusion of the value of health insurance from an employee's taxable compensation, and replacing it with a refundable tax credit of $2500 for individuals or up to $5000 for families.

"For the first time the credit will provide help to people who are shut out of the job-based insurance system; they will be able to choose an insurer or other health care arrangement, and the credit will be sent straight to the plan they pick in order to help pay their premiums," he writes. "An essential benefit of this reform is that it will help to change the whole dynamic of the current health care system by putting individuals and families back in charge and forcing insurance companies to respond with better service at lower cost."

Sen. McCain favors a state-based rather than national plan for ensuring access to care for people with preexisting medical conditions and "additional help for low-income individuals."

Sen. McCain points to his record of advocacy for medical liability reform legislation, emphasizing that it must be a central component of healthcare reform. He does not offer specifics on what tort reform under a McCain administration would look like.

"Health care reform is too important an issue for one person or one party to tackle alone, and I have a record of working across party lines to tackle big challenges and change the way Washington works. By starting with putting doctors and patients back at the center of health care decisions, we can reform the U.S. system in a way that protects the quality of care while making it affordable and accessible to all," he writes.

"The McCain Plan for Health Insecurity"

In his critique of the McCain healthcare reform plan, David Blumenthal, MD, MPP, director of the Institute for Health Policy at Massachusetts General Hospital in Boston, and an unpaid advisor to the Obama campaign, writes that "the McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care."

Sen. McCain's plan, he says, would increase patient out-of-pocket costs and reduce the role of insurance in healthcare. He notes that three fifths of Americans currently rely on employer-sponsored healthcare, and that Sen. McCain's plan would "increase reliance on unregulated individual insurance markets (which are notoriously inefficient), and leave the number of uninsured Americans virtually unchanged."

Dr. Blumenthal charges that by ending the exemption from federal income tax for employer-sponsored insurance, employers would likely drop the plans.

"Over the years, multiple studies have shown that as the tax benefit to employees of receiving employer-sponsored insurance declines, employers are less likely to offer it," he writes. "On the basis of these studies, economists project that 10 million to 28 million of the 160 million Americans with employer-sponsored insurance will lose it as a result."

The plan is also likely to encourage other employers to reduce benefits, thereby increasing employee costs, and would drive the newly uninsured into the more costly non–group insurance market, where administrative costs make up 30% to 50% of premiums compared with 12% to 15% of costs in employer-sponsored large group plans.

Dr. Blumenthal is also skeptical about Sen. McCain's proposal for establishment of association health plans (AHPs) that would allow groups of consumers to buy health insurance for their members.

"By joining such plans, individuals will presumably enjoy the protections that large groups, including employer pools, offer their members. However, the required AHPs don't exist now. If they did, they would be tempted to cherry-pick healthy members just as insurance companies do. Voluntary associations

of the sick and healthy do not naturally occur, and there is a good reason why," Dr. Blumenthal writes.

The author also states that deregulation of private insurance markets, as called for by the McCain plan, would eliminate some state mandates that insurance companies provide policies for all who wish to buy them, thereby allowing the companies to "cherry pick" the healthier subscribers while denying coverage to higher insurance risks.

Although Sen. McCain calls for establishment of state-run high-risk insurance pools, such pools, established in 35 states, enroll fewer than 200,000 people, Dr. Blumenthal noted.

"The reason is that states are unwilling or unable to subsidize adequately the extremely high premiums that pools charge the chronically ill," he writes. "McCain has talked vaguely of providing additional federal funds (in the range of $7 billion to $10 billion) to help states out, but he has not detailed this part of his plan. In any case, it raises a more fundamental question: What are the long-range consequences of segregating the sickest Americans into a predominantly state-run high-risk insurance system, especially in regions that have been notoriously ungenerous toward vulnerable populations?"

The full text of the plans and critiques are available online at www.nejm.org. Also on the site is a video of a presidential campaign healthcare forum presented at the Harvard School of Public Health in Boston in September.

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Studies Detail Contrasts in Rivals' Health-Care Plans

Republican presidential candidate John McCain's health-care plan would make only a small dent in the ranks of the uninsured, at best covering about five million more people, two new reports conclude.

Democratic nominee Barack Obama would cover more people -- eventually adding about 34 million, according to one of those reports, by the nonpartisan Tax Policy Center.

Sen. Obama's plan would be costly, the center concluded: $1.6 trillion over 10 years. Sen. McCain's would cost nearly as much: $1.3 trillion over the same span. The center doesn't give either campaign credit for initiatives to reduce the cost of health care.

The advantages of the McCain plan, according to the reports, are less government regulation, a more generous tax break and, for many, more flexibility and choice in where to buy coverage.

The Tax Policy Center called its estimates for both plans preliminary because neither campaign has put out enough information to provide a full evaluation.

Similarly, a pair of studies analyzing the candidates' plans, being published Tuesday in Health Affairs, a peer-reviewed policy journal, found many details lacking.

But the campaigns have made clear what direction they would take the health-care system. The differences provide a sharp contrast for voters.

Neither plan would offer universal coverage, though Sen. Obama regularly says his would. Critics of each plan suggest the other would erode the employer-based system that currently covers some 170 million people.

The reports shed new light on the potential and the problems of each plan.

THE OBAMA PLAN:

Sen. Obama would give consumers more options, but he would increase federal regulations.

Review the candidates' positions on key issues from Iraq to health care.

He would create a new government-run plan as well as an "exchange" in which private companies would offer insurance to compete with the government plan. New rules would require that insurance companies provide coverage to everyone, at consistent prices, even those with existing ailments. Parents would be required to cover their children, and large employers would be required to cover their workers or pay a fine.

It amounts to a significant amount of new regulation, health experts Joseph Antos, Gail Wilensky and Hanns Kuttner write in Health Affairs.

"Each of these [new rules] extends the control of government over health insurance, imposing new requirements that will drive up the cost of insurance," they write.

The government-run plan would set a minimum standard for benefits that private plans would have to meet, they explain. Politically, there will be pressure to include generous benefits, they say, and that will lead to high premiums, leaving few options for those who want cheaper, more basic coverage.

[The Price of Health Care]

It is likely that companies would be required to offer the same generous benefits to their workers, they say -- another increase in government regulation.

Still, the impact on the uninsured is significant. Overall, the Tax Policy Center predicts that the Obama plan would reduce the number of uninsured by 18 million people in the first year and by 34 million in 10 years.

THE McCAIN PLAN:

Sen. McCain would reduce both state and federal regulations and give consumers more choices about where to buy health insurance.

Current law offers a tax break only to those who get insurance through their jobs. The McCain plan would give a refundable tax credit to all who find coverage: $2,500 per person or $5,000 per family. In trade, workers would pay income taxes on the value of health insurance as part of their compensation.

But, unlike a similar plan put forth by President George W. Bush last year, health benefits still would be exempt from the payroll tax paid by workers and employers, and that is why the McCain plan is more expensive than Mr. Bush's, said Len Burman, director of the Tax Policy Center.

Because people could buy insurance on their own, some would leave the employer-sponsored system, especially young and healthy people who can get a better deal on their own. Older, sicker people are likely to face problems buying coverage.

Overall, the Tax Policy Center and the four academics writing in Health Affairs project that about 20 million would leave employer-sponsored coverage, while about 21 million people would be newly covered on the open market. That is a net increase of about one million insured people.

"Many employers would be quick to drop health benefits in response to a major policy change, such as the McCain plan, that greatly altered the business case for offering benefits," the article concludes.

The Tax Policy Center projects that the number of newly insured Americans could climb in future years and perhaps reach five million people before dropping again.

The Health Affairs article, whose lead author is Thomas Buchmueller of the University of Michigan, finds other problems with the McCain plan. Because administrative costs are higher on the open market, where insurers evaluate customers individually, he predicts that coverage would be more expensive but less generous.

The McCain plan would allow consumers to buy insurance across state lines. That would give people more choices, but it also would undermine state laws that mandate certain benefits and provide various consumer protections.

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Emergency doctors dispute McCain advisor's take on healthcare

The organization representing the nation's 26,000 emergency medicine doctors fired back today at a John McCain campaign advisor who said, in effect, that as long as there are emergency rooms, no one in American is really uninsured.

The advisor, John Goodman, president of the National Center for Policy Analysis in Dallas, told the Dallas Morning News on Wednesday that emergency rooms are a last resort for healthcare for anyone because, by law, emergency rooms can't turn away a patient in need of immediate care. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American -- even illegal aliens -- as uninsured," Goodman said.

If you've been to a hospital emergency room in recent years you probably know those folks don't have a lot of time on their hands. Here's what Dr. Linda Lawrence, president of the American College of Emergency Physicians, had to say about Goodman's remarks:

"Emergency physicians can and do perform miracles every day, but taking on the full-time medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive healthcare reform policy that should be at the heart of the platform of any presidential campaign."

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Americans Opt by Landslide for Wholesale Revision of Healthcare System

An overwhelming proportion of Americans believes the nation's healthcare system needs a fundamental change or a complete overhaul, according to the results of a survey released today.

And the next president is just the person to stimulate such reforms, said nine of every 10 respondents in the survey of a geographically representative sample of 1,004 adults, conducted on May 23 through May 27 by Harris Interactive for the Commonwealth Fund. Democrats support major changes more than Republicans do, the survey found.

"A majority of adults look to the next president to lead by proposing reforms that could improve the quality of healthcare, ensure affordable care, and decrease the number of uninsured," the survey report said. "Across income levels, region, and political affiliation, adults want presidential candidates to focus on health reforms in each of these areas."

"About nine of 10 adults say it is important for presidential candidates to have reform proposals that would improve the quality of care (90%), ensure care and insurance are affordable (93%), and decrease the number of uninsured (88%). In fact, a majority think these policy priorities are very important."

Irrespective of income, 32% of the respondents called for a completely rebuilt health system and another 50% percent thought it required fundamental changes.
Eighty-one percent of respondents who were insured all year and 89% who were uninsured at some point during the year called for fundamental change or complete rebuilding.

About nine out of 10 respondents think the next president should take steps to improve healthcare quality, reduce the cost of healthcare and decrease the number of uninsured people.

The majority of respondents (73%) expressed frustration with their recent healthcare encounters including difficulty getting regular doctor's appointments, receiving advice and seeing a clinician during non-office hours.

Part of that dissatisfaction stems from the fragmented state of the healthcare system, said Stephen C. Schoenbaum, M.D., executive vice president for programs at the Commonwealth Fund. Dr. Shoenbaum said patients "see the system as not well-organized and not well-coordinated."

About half of the respondents reported organization-related problems, such as having to call numerous times to retrieve a test result, or getting to an appointment before their test results arrived.

Respondents also expressed frustration with the amount of medical paperwork, duplicative tests, and what they deemed to be unnecessary treatments.
Patients cited electronic medical records and better collaboration between providers as possible fixes. The survey found that nearly nine out of 10 adults think doctors should use computerized medical records, access test results electronically, and share results with other doctors electronically. More than half of respondents would also like to be able to schedule appointments and communicate with their physician via the Internet.

"Strong public support for the use of health information technology stands in stark contrast to actual practice in the United States," researchers said, citing an earlier study that found just 23% of primary care physicians use electronic medical records.

Most respondents (91%) answered that it is "important," or "very important," to have one place or person responsible for managing their care.

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Commentary: McCain's Healthcare Plan

Sen. John McCain Thursday tried to distance himself from the embarrassing statement of one of his top economic advisers ex-Sen. Phil Gramm that the financial distress felt by so many Americans was simply a "mental recession."

But, the presumptive Republican nominee for President has his own disconnect with the American public with the inadequate healthcare plan he has proposed.

OK, it's easy enough to pile on ex-Sen. Phil Gramm for mocking the plight of Americans losing their homes by saying it is all a "mental recession."

Of course, from the rarified environment Gramm rides around in, he's probably not noticed the 59 percent of Americans who told a June Kaiser Health tracking poll that they are having a "serious problem" with paying for gas, getting a decent paying job, or health care or food bills.

But while John McCain tries to distance himself from the mess created by Gramm, one of his top economic advisers, the soon-to-be Republican nominee, seems to have his own let them eat cake perspective on one of the most critical issues of this campaign, health care.

It shouldn't be much of a stretch to discover the deepening crisis on health care felt by so many American families. Take the June report in the Wall Street Journal, a paper the McCain team no doubt manages to read, citing a survey of 18,000 Americans who said they'd delayed or gone without needed medical care due to the cost.

Or the Robert Wood Johnson study in April showing premiums for families who get employer-sponsored health coverage have jumped 10 times faster than workers' wages in this decade.

Or the New York Times report in June about the insurance companies that now reject the applications for coverage from women who given c-section births.

But with our health care safety net collapsing and more people going without health coverage and self-rationing care, McCain seems to be frozen in the abysmal status quo. His healthcare plan offers little relief from the present morass, and, if anything, is likely to make the crisis worse.

McCain's healthcare platform rests on four very wobbly legs:

Tax credits to encourage the uninsured to buy private insurance. But once a year tax credits are of minimal help for those living paycheck to paycheck, especially with no controls on ever skyrocketing premiums, co-pays, deductibles, doctor's fees, and a mountain of other out-of-pocket costs.

Expanding federal support for state "high risk pools" as the dumping ground for people with pre-existing conditions (or, as Barbara Ehrenreich calls them, prior convictions) who the insurance companies refuse to sell policies to. But, in a devastating critique of this scheme this week, the New York Times noted that the state plans are largely a failure. Almost all impose long waiting periods, up to a year, before allowing you to enroll, and all have very high costs for getting in. Florida closed its pool in 1991, and the current membership is just 313 people, rather a small percentage of the state's population. And, by the way, McCain has no proposal to pay for a federal expansion of this train wreck.

Eliminating the tax deduction for employer-sponsored coverage. The inevitable result will be to make health benefits less attractive to employers, meaning the decline of employer-based plans would become an avalanche -- and far more risk and financial burden will be shifted to families and individuals who hardly need more financial worries in the present "mental recession," as Phil Gramm puts it.

More deregulation of the insurance industry to encourage competition, McCain's prescription for controlling the ever rising costs. It's hard to imagine a more friendly administration to the avatars of deregulation than the one currently in office, during which premiums alone have gone up 78 percent the past six years for family coverage under employer plans, as the Atlanta Journal Constitution noted July 6.

Further, the notion that insurances compete by offering expanded access or reduced out-of-pocket costs requires much suspension of disbelief. Insurers compete by lowering their own costs, to increase company profits and shareholder return. How do they lower costs? By denying medical claims which they ghoulishly term "medical loss ratio," dumping enrollees when they get sick, and reducing services that are covered.

Since he is so averse to regulation, it's not surprising that McCain has nothing to offer the tens of thousands of patients and families grappling with insurance company decisions to deny medical procedures recommended by their doctors, or delay care, or reject diagnostic procedures or referrals to specialists, or impose higher charges for going "out-of-network." Apparently those problems don't even exist.

McCain hasn't yet said the nation's healthcare crisis is psychological, but it sure looks like all he's offering are words of encouragement and placebos.

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McCain Plan to Aid States on Health Could Be Costly

PIKESVILLE, Md. — If Senator John McCain’s radical plan for remaking American health care is to work, he will have to find a way to cover people like Chaim Benamor, 52, a self-employed renovator in this Baltimore suburb. Mr. Benamor never found it necessary to buy insurance before having a mild heart attack last year and now, 13 years shy of Medicare, has little hope of doing so.

The heart attack left Mr. Benamor with a $17,000 hospital bill, $400 in monthly prescription costs and a desperate need for insurance. After being rejected by a number of commercial carriers, he turned to the Maryland Health Insurance Plan, one of 35 state programs for high-risk applicants whom no private company is willing to insure.

He decided that the annual premium — $4,572 for a plan with heavy deductibles — was more than he could handle on an income of about $35,000. Yet his earnings were too high for him to qualify for state subsidies.

“I’d like to get it, but what do you pay first?” Mr. Benamor asked at his dining room table. “Do you pay the mortgage? Do you pay your child support? Do you pay your car insurance? Do you pay for your medicine?”

In late April, Mr. McCain, Republican of Arizona, announced that if elected president he would seek to insure people like Mr. Benamor by vastly expanding federal support for state high-risk pools like Maryland’s, or by creating a structure modeled after them. But as Mr. Benamor’s case demonstrates, even well-regarded pools have served more as a stopgap than a solution.

Though high-risk pools have existed for three decades, they cover only 207,000 people in a country with 47 million uninsured, according to the National Association of State Comprehensive Health Insurance Plans. Premiums typically are high, as much as twice the standard rate in some states, but are still not nearly enough to pay claims. That has left states to cover about 40 percent of the cost, usually through assessments on insurance premiums that are often passed on to consumers.

Health economists say it could take untold billions to transform the patchwork of programs into a viable federal safety net. The McCain campaign has made only a rough calculation of how many billions would be needed and has not identified a source for the fi-nancing beyond savings from existing programs. Finding the money will only get more difficult now that Mr. McCain has pledged to balance the federal budget by 2013, which already requires a significant reduction in the growth of spending.

Mr. McCain’s proposal stands in sharp relief to that of his Democratic rival, Senator Barack Obama of Illinois, who wants to require insurers to accept all applicants, regardless of their health. That is now the law in five states, including New York and New Jersey.

For those who can afford the premiums, or who qualify for subsidies in the 13 states that provide them, the high-risk programs can be a godsend.

Richard and Susan Logan, both of whom have battled cancer this decade, said they were grateful to have coverage for themselves and their daughter through the Maryland plan, even though it will cost $22,232 this year. They had been rejected by 25 commercial insurers, said Mrs. Logan, 57, a part-time billing clerk for a physician.

The Logans, who live in Gambrills, near Annapolis, estimate that without the high-risk pool, they would pay $40,000 a year for medication alone.

“The plan’s worth its weight in gold for that,” said Mr. Logan, 62, an aviation accident investigator. “Otherwise, we’d be paying for the medications out of our retirement.”

A fifth of the 14,000 participants in the Maryland plan receive subsidies that drop their premiums below the market rates charged to healthy people, said Richard A. Popper, the plan’s director. But many in the middle find the policies both unaffordable and intolerably restrictive, and Mr. Popper estimates that two-thirds of those eligible have not enrolled.

Almost all of the state pools impose waiting periods of up to a year before covering the health conditions that initially made it impossible to obtain insurance. In some states, fiscal pressures have forced heavy restrictions in coverage and enrollment. Florida, which has 3.8 million uninsured people, closed its pool to new applicants in 1991, and the membership has dwindled to 313.

An informal survey by the American Cancer Society recently found that only 2 percent of nearly 2,700 callers to its insurance hot line enrolled in high-risk pools within two months of being referred to them. “In most cases, we know they probably didn’t apply because they discovered high premiums or pre-existing condition clauses and just didn’t bother,” said Stephen Finan, associate director of policy for the group’s Cancer Action Network.

There is no census of the medically uninsurable. But in 2006, insurers turned down 11 percent of all individual applicants for medical reasons, including 22 percent of those 50 or older, according to America’s Health Insurance Plans, an industry trade group.

Finding a way to cover the sickest of the uninsured is critically important because 15 percent of the population is responsible for three-fourths of health care spending. Many wind up in emergency rooms, which cannot legally reject them, leaving hospitals with more than $30 billion in unpaid bills each year.

Mr. McCain’s proposal, which he calls the Guaranteed Access Plan, would be part of a market-based restructuring that is in many ways more fundamental than the universal coverage proposed by Mr. Obama.

With the goal of making the insurance marketplace more equitable and competitive, Mr. McCain would end the longstanding exclusion from income taxes of health benefits paid by employers. The 17 million nonelderly people covered by directly purchased insurance do not enjoy that advantage.

Mr. McCain would replace the exclusion with refundable health care tax credits of $2,500 per person and $5,000 per family in the hope of driving consumers into the individual insurance market. To help push down premiums, he would allow the purchase of policies across state lines.

Currently, those who buy insurance individually often face higher costs because their risks are not spread across broad groups of workers. Though insurers cannot discriminate against participants in group plans, they evaluate consumers seeking individual coverage case by case to determine if they are worth the risk of coverage, and at what price. Insurers contend that if they had to charge the same rates to all comers, many would wait until they were sick to buy policies.

The McCain campaign recognizes that in an invigorated individual market, even larger numbers of chronically ill people would go without the protection afforded by group coverage. High-risk pools would theoretically serve to fill the gaps.

Critics argue that, to date, insurers have benefited from the state pools as much as the uninsured. As long as premiums remain above market rates, the pools insulate commercial insurers from the greatest risks while giving customers little incentive to abandon their private policies.

“They are run in ways that protect the profitability of commercial insurers,” said Karen Pollitz, a professor at Georgetown University who has studied high-risk pools and who has served on the board of the Maryland plan. “They leave the illusion that there’s a safety net without there really being much of one.”

Mr. Obama’s plan differs from Mr. McCain’s in several ways. In addition to requiring insurers to accept all applicants, he would require that parents obtain insurance for their children. To make premiums affordable, he would create a Medicare-like government plan that would be open to all and pump up to $65 billion a year into subsidies. The money would come from repealing President Bush’s income tax cuts for those earning more than $250,000 a year.

When Mr. McCain unveiled his high-risk pool proposal, his chief domestic policy adviser, Douglas Holtz-Eakin, the former director of the Congressional Budget Office, estimated the federal cost at $7 billion to $10 billion. Mr. Holtz-Eakin said five million to seven million uninsured people would be singled out for coverage.

But in a recent interview, Mr. Holtz-Eakin emphasized that the projections “could change dramatically” depending on how the program was structured.

Mr. Holtz-Eakin and other McCain health advisers, including Thomas P. Miller, a resident fellow at the American Enterprise Institute, and Stephen T. Parente, a health economist at the University of Minnesota, said premiums would probably be capped at twice the standard rates. They said subsidies might be available to those making up to four times the federal poverty level, or $41,600 for a single person.

Financial incentives would probably be provided to those who effectively manage their diseases. No decision has been made about waiting periods for pre-existing conditions, the advisers said.

Mr. McCain’s proposal would represent a huge increase over the $50 million a year that Congress now appropriates in grants to the state pools, in a program that began in 2002. But several analysts questioned whether even $10 billion would be nearly enough, given that the states now spend about $2 billion to insure 207,000 people.

“I do not for a minute think it will cost 7 to 10 billion dollars a year,” Ms. Pollitz said. “It may cost 7 to 10 billion dollars a week.”

In an admonition for Mr. McCain, Maryland’s five-year-old plan, like others before it, has quickly become a victim of its growth. As enrollment expanded by 30 percent in each of the last two years, actuaries forecast insolvency as soon as 2010 and compelled the plan’s board to apply the brakes.

Over the last two years, it has raised premiums, deductibles and co-payments, increased out-of-pocket maximums, lowered the lifetime cap on payments and added a waiting period for pre-existing conditions, which rose to six months from two months on July 1. It also increased the amount applicants must pay to buy their way out of the waiting period.

At the same time, the plan is making more people eligible for subsidies. To keep it afloat, the state is raising the assessment on hospital bills that provides two-thirds of its financing.

“It’s not easy when you see there is strong demand for something and you need to temper that demand,” Mr. Popper, the plan’s director, said. “But you either find a way to slow enrollment through economic forces or you close the plan and no one gets in, which is a solution that no one wants.”

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Health Care Made Simple

Medicare? Over time, Emanuel's plan would completely phase it out. Medicaid? Same idea.

(Book Review from Newsweek):
Emanuel, an oncologist who chairs the department of bioethics at the National Institutes of Health, advised the Clintons on their disastrously complex health-care plan of 1993. He's come a long way since: he now seems to subscribe to the "keep it simple, stupid" school of policy design. Too many details can scare away those of us who aren't wonks, so he mostly leaves them out of his new plan. Instead he proposes big, systemwide changes, starting with the butchery of some of health care's most sacred cows. Medicare? Over time, it would be phased out. Medicaid? Same. Employer-based health insurance? It's a bureaucratic system built "by accident," he writes, originally designed for post-World War II workers; let's get rid of it. In place of all these institutions, Emanuel says, the government should offer every American a voucher for health insurance—one that covers the same benefits that members of Congress get. Insurance companies would have to accept the vouchers, and each person could choose from a variety of private networks of docs, hospitals and health plans. A National Health Board would oversee it all. And that's pretty much it.

Now the big question: how do we pay for it? Emanuel's plan lowers some taxes by gutting costly programs, but it also adds a new fixed tax on some goods and services to pay for the vouchers. "Americans will come out revenue-neutral on average," he says. "The poor will pay less." And the rich will probably pay a lot more. Sweeping changes are one thing, but sweeping changes and a new tax? Even if the plan could save health care, it'll be a hard sell.

...While he likes Barack Obama's and Hillary Clinton's proposals more than John McCain's, he's underwhelmed by all of them. "I don't think anything they've put out so far is what they're going to end up advocating," he says. "They'll want another plan eventually. I want to be that second choice."

(full article)

Health care on corporate agenda

The Securities Exchange Commission just decided to let corporate shareholders vote on proposals to have their corporations endorse national health care. To be more specific, the vote will encourage public companies to adopt a stand in favor of "principles for comprehensive health-care reform" --- reform that would make health care "affordable to individuals and families, and affordable and sustainable for society." Who can argue with that?

How we make it happen is the $2 trillion dollar question. Major corporations killed Bill Clinton's attempt back in 1994, because they were certain that it would increase their costs. Today, however, we are competing in a world economy where all other countries spread medical costs over all taxpayers instead of just those who happen to work for companies.

Companies in foreign countries are not saddled with the brunt of medical care costs for all current and retired employees. Stockholders of our major companies are now waking up to the fact that their investments may do better if health-care costs are treated as social costs rather than those built into the cost structure of a manufactured product.

One would think that some senior executives whose bonuses and options are tied to company profits would jump at any chance to foist those health care costs off on the taxpayers --- on the "little people." This Wall Street Journal years ago pointed out that executives who do the math would clearly support national health care, but that they resist the notion for fear of being ostracized at their country clubs.

(full article)

McCain's Health Care Plan Leaves Us Sick

McCain Offers Details of His Health Plan


Blogosphere reaction

McCain's Healthcare Plan is the Worst

Davis Liu, MD has written a critique of McCain's healthcare plan - it's brilliant in its clarity and I am delighted to repost it here. Click here for his blog.

McCain's Healthcare Plan is the Worst -
Consumer Driven Healthcare Not the Answer

FORTUNE magazine published an opinion piece in their March 17, 2008, issue titled Why McCain has the best health-care plan. McCain like many of his fellow Republicans believes that giving individuals more responsibility is a way to solve the healthcare crisis.

Frankly, expecting Americans will use tax incentives to find their own healthcare insurance is laughable. Already when tasked to fund their own retirement, the vast majority don't want the responsibility, are inadequately prepared and planning to work longer. This is despite planning for their retirement is in their best interest. Who wants to be forced to work longer if they don't have to? Companies are discovering that although they relinquished their responsibility of helping their employees' retirement by eliminating the pension plans for the cheaper 401k plans, workers are not better off. Many workers even fail to enroll in the 401k plans and many that do are only invested in the money market option, which won't keep up with inflation. Now many employers are stepping in, requiring mandatory 401k enrollment (workers can opt out), and defaulting the funds into a mutual fund that has better returns.

Experts who believe that the consumer will make the right choices when given the important job of finding their own health insurance, funding it, and making best use of it obviously aren't aware of the consumer experience with retirement planning. An entire industry has developed to help people plan for retirement. Will the same occur in healthcare? Who will be the healthcare advisors? Doctors? Insurance agents? A new field of advisors?

If the public approaches the responsibility of healthcare insurance the same way it does with personal retirement planning, our country is in big trouble. Unfortunately unlike postponing retirement, a person can't predict or delay when he will get ill. Relying on the public to shop for healthcare will result in many more being uninsured, others not getting preventive care, and a workforce that will be increasingly unhealthy and unable to compete in a global market. As an insider I know what to do in this new world, but what about the rest of us? Specifically, what about you?

Note: Also, see his post Republican Healthcare Proposal Is Not Universal Coverage

McCain

McCain's health care plan is designed to protect health insurance companies.