The Zong

As someone who became hyper-aware of the difficulties facing the uninsured and underinsured American (by force) a few years back. This issue is pretty close to the most important thing on the agenda for me looking at the presidential race. Again, it slips down to number 4 on my list because of the massive similarities between the democratic candidates, but unlike environmental and energy issues, these three health care plans are actually pretty different, and much to the dismay of myself and others, I have to admit that Hillary is right: only two of them are universal health care plans.

Before getting into specifics, I have to briefly cover my own idealistic transformation on this issue. I believed for a long time, and continue to believe, that the only real permanent solution to this problem is the dreaded single-payer system of health care. I used to be very vocal about it, because I can’t really see how anyone in the whole country doesn’t appreciate the value of such a system; Liberals are for it because it covers everyone and makes the entire population healthier, and conservatives SHOULD like it because it takes a huge financial burden off of the shoulders of their old flame, Big Business. Alas, due to an insanely strong insurance and pharmaceutical lobby and the conservatives’ creed involving not taxing the rich, it has become clear that the single-payer system isn’t gonna happen overnight. Thus enters the great compromises offered by our three contestants:

Barack Obama is a great speaker. He really, really is. I have a lot of faith in his ability to lead this country and will vote for him in the general election without a shred of remorse or reservation, if it comes to that. That said, after reading his health care plan, I’m unhappy to report that it probably the weakest of the three. Short on actual numbers and long on pie-in the sky, here’s the basic rundown:

• Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions.
• Comprehensive benefits. The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential medical services, including preventive, maternity and mental health care.
• Affordable premiums, co-pays and deductibles.
• Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.
• Simplified paperwork and reined in health costs.
• Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage.
• Portability and choice. Participants in the new public plan and the National Health Insurance Exchange (see below) will be able to move from job to job without changing or jeopardizing their health care coverage.
• Quality and efficiency. Participating insurance companies in the new public program will be required to report data to ensure that standards for quality, health information technology and administration are being met.

This summary sounds great. The problem is, if you read the details of the plan, for me at least, it raises many more questions than it answers. While the plan does an impressive job of gathering important statistics which tell the sad story of our country’s broken health care system (you can download the PDF and all its endnotes here), I get kind of tired of reading the following solutions to these problems:

Obama will require providers to report preventable medical errors, and support hospital and physician practice improvement to prevent future occurrences.

Obama will accelerate efforts to develop and disseminate best practices, and align reimbursement with provision of high quality health care.

Obama will require that plans that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs.

There is a lot of this kind of rhetoric in the Obama plan, and even without getting into specifics, it’s kind of easy to see that these types of measures suffer from a special kind of optimism that is easy to have when you don’t have to describe exactly how you’re going to get the stuff done. As far as I can tell, the plan doesn’t detail much other than just to say Obama’s gonna “require” and “support” and “accelerate” a lot of shit without getting into anything more specific than that. Do the other plans have this kind of language? Hell yes, but I happen to think they do a better job of qualifying their promises. In addition, many of the stated measures involve a lot of meddling with hospitals, requiring more paperwork and relying on “universal standards” that don’t exist yet. Who decides what the best way to treat a rare type of cancer is, and if someone disagrees (like, say a respected oncologist), you’re gonna penalize his hospital for treating someone differently? I’m all for big government, but this sounds kinda like the way George W. Bush tried to tackle our education problems. I’ll call it “No Tumor Left Behind.”

A couple of large, specific problems I have with the Obama plan are his lack of a personal mandate to get covered and his National Insurance Exchange. Taking the latter in hand first, it is described thus:

The Exchange will act as watchdog and help reform the private insurance market by creating rules and standards or participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible.

As much as I love watchdog groups, I generally like them in the form of independent nonprofits (see: John Edwards’ plan) rather than in the form of government-run sinkholes for money that should be used for subsidizing public health care. This calls to attention the size of the subsidies endorsed by Obama’s plan. While all three candidates plan to subsidize insurance for those who can’t afford it, Obama’s plan actually subsidizes much less than the other two (Obama does not offer subsidies to small businesses and will not commit to a specific expansion of SCHIP and Medicare), and because of its lack of a mandate, the cost of health care will actually be more expensive for those who need it.

Speaking of mandates, which are truly people’s new favorite awesome when it comes to health care, Obama’s plan will leave approximately 8.5 million Americans uninsured (as stated by ontheissues.org), which is a great improvement over 46 million, but certainly isn’t universal. It’s true that Massachusetts’ new health care mandate is meeting with mixed results, but it’s early yet. The simple fact is that, for any of these crazy plans to be affordable, everyone has to share the responsibility, and that’s kind of an immutable fact. Do I wish it wasn’t so? Sure, but it is so, and So Obama comes in last in this horse race.

Between Clinton and Edwards, there are far fewer differences. Both point to specifics when it comes to not only their plans to reform healthcare, but also how they plan to do it. Both plans call for “shared responsibility,” which I really like, and Clinton even has a balance sheet detailing the financing of it. (I’m skeptical of its accuracy, but I guess Hillary Clinton probably knows a little more about the cost of national health care than I do.) Both of them plan to subsidize low-income families using a tax credit, and John Edwards actually promises to refund tax dollars to those who make so little that they don’t pay income tax. This means that, to begin with, the plans favored by both the candidates will cost more than Obama’s plan subsidy-wise. Clinton has as much as guaranteed new taxes to pay for it (really, a repeal of the Bush tax cuts), which I think is inevitable, but Edwards has a creative, and hopefully not completely unrealistic way of bringing overall health care costs down that he refers to as the Health Care Markets. As described by his campaign:

The U.S. government will help states and groups of states create regional Health Care Markets, non-profit purchasing pools that offer a choice of competing insurance plans.

I can actually see a lot of value behind this idea, mostly in the spirit that it will line up the available plans for all Americans and allow people to make an educated choice based upon straight comparisons. I’m assuming that, though he doesn’t explicitly state it, he’ll try to make his public health care plan a lot more appealing than the private ones, if not simply less expensive. In addition, it will force private insurers to compete with the public plan, which is good for everyone, and what I really like is this line:

This American solution will reward the sector that offers the best care at the best price. Over time, the system may evolve toward a single-payer approach if individuals and businesses prefer the public plan.

This whole thing is pretty ambitious and will require a lot of government administration to work, I admit, but it seems to make a lot more sense than Obama’s national insurance exchange. Most importantly, the option for the plan to evolve into a single-payer system makes it that much more appealing.

That said, I’m not an idiot. I know that none of these plans is probably going to work out, at least not the way they’re being outlined, but I’m trying to figure out which one I think is the most likely to work. Are you ready for this? I think it’s Hillary’s plan.

Hillary Clinton’s failure to achieve universal health coverage as First Lady is widely pointed to as a liability, but I’m actually of the opinion that she learned her lesson. After reading her health care plan, which is quite simply the most detailed and possibly the most realistic of the three, I’m kind of convinced that, with the right congressional support, she could get it done. There isn’t any fancy nonprofit watchdog scheme, and I think that the idea of a health-care menu is pretty stupid, but I’m trying to look past the gimmicks here. The fact is that, while I find choosing health care options to be much more important than choosing what I want on my next burger, the Clinton plan may actually be the best of the three just based upon its simplicity; she plans to tax the rich to cover the poor, and create a public plan to compete with the private plans. Sounds pretty similar to the other two, but the key here is that the plan options will simply be a broad expansion of the Federal Employee Health Benefit Program. I’ve always kind of thought that when candidates say “You’ll have the same health care plan that Congress does!” that it’s a bunch of gimmicky bullshit, but the fact is that enrollment in the FEHB will be like national enrollment in a group health care plan, with the public plan (essentially an expanded version of Medicare) listed as an option, and I guess that seems like a more direct, easier-to-get-through-congress type of approach.

It’s fair to mention here that Edwards was in front of the pack on this issue (again), and all the similarities you’ll see in the three plans are probably a result of the other campaigns simply trying to match what he outlined at the outset. This is yet another reason that Edwards seems like a great candidate to me, and it certainly seems as if universal health care is among the more important causes to him. In stark contrast to what Obama is proposing, I think a lot of thought and tough decisions were made when formulating the Edwards plan, and his campaign came up with a great (if not difficult to implement) compromise. As much as all us sane folks want a single-payer system in this country, it’s simply not realistic at this point, but I do believe that the Edwards plan is the one plan that will push towards single-payer in the future.

That said, it’s important to get something done, and I just think that Hillary’s plan, though she piggybacks Edwards on many points, is much more of an achievable goal. I’m certainly not voting for her in the primary, but if this was a one-issue election and that issue was health care, I’d have to consider it.

Next Up - Education.  Who will truly make sure our kids is learning?

- M.G.