Sunday, February 3, 2008

Top Three Presidential Candidates Health Care Reform Proposals

Leading Presidential Candidates-Clinton, McCain, Obama Proposals for Health Care Reform
Two weeks ago I wrote an article about the five fundamental questions that need to be asked in order to design optimum health care reforms in the United States. This week’s column analyzes the leading presidential candidates Senators Hillary Clinton, Barak Obama, and John McCain proposals on health care reforms and how their ideas would address these five concerns:
Access to Care
Optimization of Government Purchasing for Medicare and other Programs
Reimbursement Alignment for Desired Clinical Outcomes
Streamlining the Health Care System Administratively
Financing Health Care for all

Access to Care
The three questions that must be addressed in order to answer the access question are:
Do the proposed changes provide health care coverage for all residents, or at least a close approximation of that?
Secondly, do their proposals address adequacy of reimbursements for health care clinicians and facilities?
Thirdly, are there enough clinicians to meet the increased demand for primary care and other services from changes in health care access and if not, what is being proposed by the candidate?
Of the three presidential candidates, Clinton, Obama, and McCain, only one opposes a mandate for health coverage and that is Republican McCain. Of the two leading Democratic candidates, Clinton would require every resident to have health insurance coverage and require large employers to provide employee health care or contribute to the cost for it. Obama would require all children to have health insurance and require employers to offer "meaningful" coverage or contribute to the cost of a public health plan. There would be limited change in access to health care with McCain’s stance, while Obama and Clinton would increase the number of people who could afford to access health care via insurance due to mandates and subsidies. In terms of expanding existing public programs, Clinton and Obama would expand Medicaid and SCHIP, the supplemental children’s insurance program, whereas McCain would only expand Veteran’s benefits. Obama would create a National Health Insurance Exchange for small businesses and individuals without access to other public programs, to offer health insurance through private plans or the new public plan. Clinton would offer a similar health choice menu for public or private plan enrollment.
McCain’s position to reimburse Medicare and presumably Medicaid on a single fee for coordinated care, could help increase access to more pediatricians and other primary care providers. If private insurance would become more available to a portion of the uninsured, this would allow these individuals to obtain care more readily than through Medicaid.
In terms of investing in health care infrastructure to increase the supply of nursing and other health care professionals, McCain does not address this, but Clinton and Obama propose an increase in federal funding for training more nurses. Obama also proposes improvements in reimbursements, training grants, and loans for health care professionals.

Optimization of Government Health Care Programs
To create more value from currently funded government programs, McCain would encourage risk-adjusted payments for Medicaid, coupled with private insurance. He also alludes to alternative forms of access and different licensing for providers. For cost containment he would adopt malpractice reforms, health care anti-trust laws, transparency in pharmacy pricing, and change regulation from state to national for health insurance marketing purposes. McCain would also support public health initiatives for chronic disease prevention, health education, and reductions in obesity, diabetes, and smoking.
Clinton’s platform permits the federal government to negotiate RX prices for Medicare directly with manufacturers, change patent laws to increase the availability of generic drugs, and limit pharmaceutical advertising to consumers. She would also encourage disclosure of medical errors with liability protection for physicians. Clinton would also support more federal funding for reducing health disparities, developing quality measures, and strengthening consumer protections for long-term care.
Obama’s ideas for optimizing government programs include promotion of generic drug programs, allowing importation of drugs from other countries, and direct negotiations with drug companies for the Medicare program. He would also reform malpractice and strengthen anti-trust laws in health care. Like Clinton, he supports the creation of an independent institution for review of medical errors, to establish quality standards, and create measures.

Reimbursement; Paying for Desired Clinical Outcomes
McCain would change clinician reimbursements to a single coordinated payment for care, rather than fee for service. He would also bar payment for preventable medical errors or mismanagement by health care providers. He would also provide Medicare payments for patient care coordination and prevention.
Clinton would provide federal recognition for physician driven certification for best practices and incentivize quality through an increase in federal reimbursements for Medicare. Like McCain, she would not pay for preventable infections and other medical errors. She also wants to reduce reimbursements on the Medicare Advantage Plan to the equivalent of Medicare, which is considered inadequate compensation by many physician groups.
Obama would reduce Medicare Advantage Plan reimbursement to the same level as Medicare, which could impare access to primary care. He also advocates creation of a new public health plan, similar to the federal employees health plan, which could be expensive. (Clinton talks about using the federal employees’ plan as a model too.) Obama does not specify how he would reward clinicians for chronic disease management or other health care goals. Obama has concentrated on the consumer and insurer aspects of health care, but does not seem to have spent much time reviewing clinician impacts.

Streamlining Health Care Administratively
All three candidates support deployment of a national medical records standard, but McCain does not specifically allocate federal funds in his platform. McCain advocates national standards for insurance regulation, not state, which would allow more competition from vendors. This would also allow national standards and certification for health insurance offerings. He would encourage alternate forms of access and licensing for providers and establish national standards for measuring health outcomes.
Clinton would require all private insurance carriers to offer coverage on a guaranteed issue and renewable basis, creating one national standard. She would also move to establish community rates, rather than variations based on health and other factors. Clinton would require private insurers to meet minimum loss ratios, which means a high value of every dollar collected would have to go for consumer benefits. She would also require coverage for preventive care. She would encourage regional purchasing cooperatives, where states can band together for optimal purchasing and stabilization of health care financing. Clinton would establish national standards for prevention of health disparities, technology for electronic medical records, chronic care management, best practices, and medical error disclosure.
Obama would create a National Health Insurance Exchange for residents to obtain coverage through private or public health plans. This is a first step in creating a national platform to educate consumers on health care options, setting one standard instead of fifty. Like Clinton, he would also require coverage to be guaranteed issue and that the plans meet standards for benefits and quality. The exchange would conduct the evaluations and communicate the values. He would maintain existing state health care reforms if they meet the minimum standards for the national health plan. He would support the creation of an independent quality institute for health care, to analyze data, and promote ways to minimize health chronic disease. Obama would also promote new models for addressing physician errors along with reforming malpractice laws.

Financing New Health Care Ideas
One of the key components of any health care reform is the financing. Presently health care is provided through the FICA Medicare tax, which is 1.651% of wages, matched by employee and employer, state taxes for Medicaid, general funds from the U.S. government, employer contributions which are heavily subsidized by tax deductions, and individual contributions. In a later issue, the healthpolicymaven will review how all of these stack up, but for now, here is a summary of the top three candidate’s ideas for financing health care reforms.
Senator McCain would finance health care expansions by reforming the tax code, including eliminating tax preferences for employer paid health benefits and allowing individuals to purchase multi-year health care contracts through Health Services Accounts (medical savings accounts). He also advocates a tax credit for individuals and incentives to obtain insurance coverage. He would contain costs through changes in provider reimbursements, tort reform, and quality improvements. Senator McCain did not have a budget posted for his reforms as of January.
Senator Clinton would require individuals who earn more to pay more for a national health care program. She would provide a tax subsidy to help families obtain health insurance. She would not phase out employer provided health plans, but would require large employers to provide health care. Senator Clinton estimates her reform package would cost a 110 billion a year after it is fully implemented, but has identified 21 billion saved by the reduction of uninsured and existing Medicaid payments to hospitals. She has identified another 54 billion in revenue recapture by limiting the employer paid health insurance tax exclusion and limiting the tax cuts for individuals with incomes over 250,000.
Senator Obama would expand federal programs and create the National Health Insurance Exchange. If employers do not offer health care to employers, they would be required to contribute to the cost of the federal option for their employees. Obama’s annual estimate for the cost of his health plan reforms is 65 billion, which is half of Clinton’s. This seems grossly unrealistic when you consider that just covering the 46 million people who are uninsured, at the cost of the average private employer plan of $4,479 per year would equal 206 billion. How is he going to cover the 46 to 50 million uninsured without a significant budget increase?

In conclusion, of the three candidates, Hillary Clinton has been the most explicit and realistic in terms of what her health care proposal would cost, initially, and ultimately.
Since the financing of health care reforms is very complicated, the next posting at will review various budgets for the proposals. All reference material for candidate positions was gleaned from the Kaiser Family Foundation web site at:

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

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