As progressives, one of the most important issues for us in this next presidential election is (or should be) health care reform. More specifically, the chance of finally achieving truly universal health insurance coverage in the United States. This has been a goal of the progressive movement in this country for over 100 years now, and frankly, it's an embarrassment that it hasn't been achieved yet. Currently we stand alone amongst first-world democracies as the sole nation not to have such a system of universal coverage in place.
So, let's take a look at the plans put forth by the current field of Democratic presidential candidates...
Hillary Clinton
We're all familiar (at least somewhat) with Hillary Clinton's efforts to produce a national universal health care reform plan in 1993/1994 while leading a commission created by then president Bill Clinton. The results of this effort were the Health Security Act of 1993 which, thanks to lack of support and health care industry attacks, fell flat. Often derided as "HillaryCare" this plan represented a compromise between a government controlled system and a free market based system. It is often erroneously called a single-payer plan. One interesting thing about the failed plan is that many of the 2008 Democratic presidential candidates borrow elements from it. In John Edwards case, quite extensively.
Plan Summary
Clinton has not yet outlined her entire plan yet, but she has come out publicly saying that her first step in providing universal coverage is through expansion of the SCHIP program to cover all Children (I assume, similar to what we do here in Illinois). From what she's said so far on the subject, the best description of what her final plan will look like is "cautious, safe, and pragmatic".
On her website under the health care section, you can find the first "plank" of her health care reform plan, which is focused on her "7-Step Strategy to Reduce Health Costs While Increasing Affordability, Accountibility, and Quality".
- A Groundbreaking National Prevention Initiative to Reduce the Incidence of Such Diseases as Diabetes and Cancer that Impose Huge Human and Financial Costs
- Institute a New "Paperless" Health Information Technology System
- Transform Care of Today’s Chronically Ill Population to Improve Outcomes and Decrease Costs
- Ending Insurance Discrimination to Help Reduce Administrative Costs
- Create an Independent "Best Practices" Institute to Empower Consumers, Providers and Health Plans to Make the Right Care Choices
- Implement Smart Purchasing Initiatives to Constrain Excess Prescription Drug and Managed Care Expenditures
- Put in Place Common-Sense Medical Malpractice
You can read the whole article here but basically, the gist is that first we need to "fix" the broken system before expanding it to everybody. The rest of her plan will be released in the "coming months" according to her campaign.
Will everyone be covered?
Yes, eventually, but on an incremental basis. First children, then adults with a set of legislation passed over her term(s) in office.
Is it single-payer?
No.
Cost-control measures?
This is one of the focuses of her plan actually. According to the article on her website (referenced above):
Senator Clinton’s proposals would reduce costs and improve quality in the health care system. Taken together they would lower national health spending by at least $120 billion dollars a year. If businesses received a proportionate reduction in their health benefits spending, they would achieve at least $25 billion in savings in 2004 dollars. Families would substantially benefit as well. In fact, Business Roundtable has estimated $2,200 in national health savings for the typical family. And these savings would be reinvested in the system to help cover the 45 million uninsured.
Barack Obama
One of the criticisms of Obama at first was his vague support to "universal coverage" without any details. Well, egged on by Edward's detailed plan, he's provided an excess of details on his website and in personal appearances.
Plan Summary
From the health care section of Obama's website here's the overall summary of the plan (as interpreted by me):
- Obama will propose legislation to create a new beefed-up-Medicare type public insurance plan, provided fully by the federal government with no private insurance intermediaries, that anyone could buy into.
- The new public plan will provide the same coverage as the FEHB plans.
- Premiums for those in the plan will be subsidized on a sliding scale based on income.
- Those individuals who have an aversion to "socialized medicine" for some silly reason can choose to purchase private insurance from a new national risk pool regulated by the federal government, the "National Health Insurance Exchange". Individuals purchasing these private plans will also have their premiums subsidized on a sliding scale just like with the public plan.
- Employers would be required to provide insurance coverage for their employees or pay a percentage of payroll to pay for the Obama Plan (this is where most of the funding will come from I suspect).
- Parents and guardians will be required by law to ensure that their children have coverage.
- Medicaid and SCHIP funding will be increased.
- Medicare will be unchanged.
- A new federal reinsurance program for catastrophic expenses incurred by private employer-sponsored group plans.
- Various initiatives to improve quality of care and change reimbursement to reflect quality of service.
- Creation of a national electronic health records system.
- Regulation of private insurance and drug markets to eliminate anti-competitive behavior and lower costs.
- Various initiatives to expand local and national public health programs.
Will everyone be covered?
Not necessarily. Although everyone is eligible, not everyone is required to be covered (except for children) and there is no default plan that everyone is automatically enrolled in.
Is it single-payer?
No, but Obama's plan includes aspects of a single-payer system and over time--if everyone chooses to buy into the national health insurance plan--it could very easily become single payer. A single-payer system could "evolve" over time, just as Edwards claims of his own plan.
Cost-control measures?
Several aspects of Obama's plan are focused on cost control, the most important in my opinion is the ability of individuals to buy into the public plan. This will force the private plans to compete against a public, non-profit plan with very little overhead costs, reducing costs overall.
John Edwards
John Edwards was the first of the "1st tier" candidates to present a detailed health care reform plan.
Plan Summary
From the health care section of John Edward's website:
The Edwards Plan achieves universal coverage by:
- Requiring businesses and other employers to either cover their employees or help finance their health insurance.
- Making insurance affordable by creating new tax credits, expanding Medicaid and SCHIP, reforming insurance laws, and taking innovative steps to contain health care costs.
- Creating regional "Health Care Markets" to let every American share the bargaining power to purchase an affordable, high-quality health plan, increase choices among insurance plans, and cut costs for businesses offering insurance.
- Once these steps have been taken, requiring all American residents to get insurance.
Detailed plan
Not mentioned above:
- Like in the Obama plan (Edwards had the idea first), individuals will be able to buy into a beefed-up-Medicare type public insurance plan through the regional "Health Care Markets".
- Edwards plan also has a plank creating a new national electronic health records system.
It's interesting to note how much the Edwards plan borrows from Hillary Clinton's failed Health Security Act with managed competition in the "Health Care Markets" (called "Alliances" in the 1993 Clinton plan).
Also, it's interesting to note how much Obama's plan borrows from Edwards plan. It's sort of an Edwards-lite, removing the requirement that individuals purchase insurance and making there be a single, "National Health Insurance Exchange" instead of regional "Health Care Markets" like in Edwards plan.
Will everyone be covered?
Technically everyone will be required to purchase insurance. However, how many will actually do so is up in the air. States with mandatory car insurance laws fail to ensure that 100% of drivers are insured. One way to ensure that all are insured would be to enroll everyone into the new public insurance plan as a default automatically. I know that this criticism of the Edwards plan has been mentioned on this site before.
Is it single-payer?
No, but if everyone chooses to buy into the public plan, a single-payer system could naturally evolve over time. Given the lower overhead of public insurance, I say that there's a good possibility of this happening under Edwards plan.
Cost-control measures?
As with Obama's plan, public-private competition will drive down costs. Also, investment in infrastructure an market-reforms should also help to drive down costs.
Bill Richardson
Richardson's approach is almost identical to the Kerry/Edwards plan in 2004. It borrows several simple, pragmatic Democratic ideas that have been floating around for the past decade for expanding coverage and cutting costs. It also brings in the new "mandatory forced buy" idea from the Mass. reform plan.
Plan Summary
From the health care section of Richardson's website:
THE RICHARDSON APPROACH:
- Open up existing sources of affordable, portable coverage to more Americans:
- Working families and small businesses will be able to purchase coverage through the Federal Employee Health Benefits Plan.
- Americans 55 and older will be able to purchase coverage through Medicare. Seniors and persons with disabilities will also receive all of their care through Medicare, rather than multiple, uncoordinated, inadequate programs, as they do now.
- Lower-income Americans will obtain affordable coverage through expanded Medicaid and State Child Health Insurance (SCHIP) programs.
- Veterans will get access to the high-quality care they deserve, when they need it, without bureaucratic hassles.
- Help families pay for coverage:
- An advance refundable tax credit based on income will help families obtain coverage through the FEHBP or Medicare.
- All employers will be required to do their fair share to contribute to a healthy and covered work force.
- All Americans will be required to obtain coverage once these reforms are in place.
- Provide relief from high health costs by:
- Passing a Medical Borrower's Fairness Act to provide immediate relief to families forced to borrow to pay for medical expenses.
- Streamlining health care administration through common forms, common reporting requirements, and widespread use of health IT.
- Investing in prevention by addressing the root causes of chronic diseases.
- Improving quality of care through payment systems that reward performance
Also on the site:
Will everyone be covered?
Just like in the Edwards plan, everyone will technically be required to obtain coverage. However, this isn't a 100% guarantee that everyone will. Richardson does not provide for automatically enrolling individuals in a default plan either.
Is it single-payer?
No.
Cost-control measures?
There are some cost controls, such as streamlining paperwork and investing in prevention programs.
Joe Biden
Joe Biden emphasizes his support for universal health care as one of his three top campaign priorities (along with ending the war in Iraq and education). These are priorities that I think we can all agree with. Unfortunately, his four-step health care reform plan falls short of full, universal coverage for all Americans. It's mainly focused on fixing what's wrong with the current system and expanding current programs.
Plan Summary
I'll summarize what's on the health care section of his website:
- Step One: Reduce the Cost Of Health Care
- Focusing on Prevention
- Improving Management of Chronic Diseases
- Investing In Information Technology (which would result in Improved quality of care, Improved patient-provider communication, and Reduced duplication of services and treatments)
- Requiring Uniform Billing and Claims
- Negotiating For Prescription Drugs
- Meeting the Need For New Health Professionals (including Nurses, Public Health Workers, and Physicians)
- Step Two: Cover All Children
- Drastically expand SCHIP funding and eligibility, allowing every family to buy into the program on a sliding scale
- Automtically enroll unisured children in SCHIP/Medicaid at birth
- Expand Medicaid coverage to cover more parents and childless adults.
- Step Three: Lower Health Care Costs For Employers And Provide Catastrophic Coverage
- Create a new federal reinsurance program for private group plans to cover catastrophic costs.
- Step Four: Encourage Reform In The Insurance Industry
- Allow private insurers providing individual policies to join the federal reinsurance plan as long as they agree to not deny coverage based on pre-existing conditions (guaranteed issue) and to charge everyone the same premiums (community rating)
Will everyone be covered?
No. In fact, I suspect that Biden's plan (as presented on his website) will only keep the number of uninsured from rising.
Is it single-payer?
No.
Cost-control measures?
Yes, part one of his plan is exclusively focused on cost-control measures. This is one of the few strong points of his plan.
Dennis Kucinich
Dennis Kucinich stands out as the only presidential candidate to promote a single-payer universal health care plan. He is a cosponsor of the bill H.R. 676 in the House of Represntatives.
Plan Summary
I'll summarize the actual text of the bill that Kucinich is cosponsoring:
- Replaces the existing U.S. insurance industry and all existing public health care programs with a full-fledged single payer system.
- Expands coverage to all U.S. Residents regardless of legal status.
- No co-pays or deductibles are permissible under this act.
- This program will cover all medically necessary services, including primary care, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, long term care, mental health services, dentistry, eye care, chiropractic, and substance abuse treatment. Patients have their choice of physicians, providers, hospitals, clinics, and practices.
- Private health insurers shall be prohibited under this act from selling coverage that duplicates the benefits of the USNHI program. They shall not be prohibited from selling coverage for any additional benefits not covered by this Act; examples include cosmetic surgery, and other medically unnecessary treatments.
- The National USNHI program will annually set reimbursement rates for physicians, health care providers, and negotiate prescription drug prices. The national office will provide an annual lump sum allotment to each existing Medicare region, which will then administer the program. Payment to health care providers include fee for service, and global budgets.
- The United States Congress will establish annual funding outlays for the USNHI Program through an annual entitlement. The USNHI program will operate under the auspices of the Dept of Health & Human Services, and be administered in the former Medicare offices. All current expenditures for public health insurance programs such as S-CHIP, Medicaid, and Medicare will be placed into the USNHI program.
- A National USNHI Advisory Board will be established, comprised primarily of health care professionals and representatives of health advocacy groups.
- Employers who currently provide coverage for their employees pay an average of 8.5% of payroll towards health coverage, while many employers can’t afford to provide coverage at all. Under this Act, all employers will pay a modest 3.3% payroll tax per employee, while eliminating their payments towards private health plans. The average cost to an employer for an employee earning $35,000 per year will be reduced to $1,155, less than $100 per month.
- The conversion to a not-for-profit health care system will take place over a 15-year period, through the sale of U.S. treasury bonds; payment will not be made for loss of business profits, but only for real estate, buildings, and equipment.
Will everyone be covered?
Yes, everyone will be automatically enrolled. No one can be denied coverage.
Is it single-payer?
Yes.
Cost-control measures?
According the text of the bill (and I'm summarizing here): Project savings nationwide: In its first year, single-payer will save an estimated $150 billion on paperwork and an estimated $50 billion by using rational bulk purchasing of medications. These savings are more than enough to cover all the uninsured, improve coverage for everyone else, including medication coverage and long-term care.
Chris Dodd
Chris Dodd puts forth a plan that is similar to the one proposed by John Kerry in 2004: allow individuals and businesses to buy into plans equal to the ones available to federal employees through the Federal Employee Health Benefits (FEHB) plan.
Plan Summary
From Chris Dodd's campaign site:
- Ensures all Americans will have quality, affordable health coverage during Chris Dodd's first term.
- The Dodd plan will create a health insurance marketplace called Universal HealthMart that is based on, and parallel to, the Federal Employees Health Benefits Plan (FEHBP).
- Individuals and businesses will contribute to Universal HealthMart based on their ability to pay.
- Premiums will be affordable based on leveraged negotiating power, spreading risk, reduced administrative costs, and incentives for technology and preventive care.
- Coverage will be portable -- insurance purchased in Universal HealthMart will follow individuals.
Will everyone be covered?
Not necessarily. The plan does not say that employers or individuals would be required to purchase coverage or if they will receive some sort of default coverage automatically.
Is it single-payer?
No.
Cost-control measures?
From what I've heard and read, the FEHB plans have seen less inflation than in the rest of the health insurance market through manage competition and government regulation.
Mike Gravel
Mike Gravel supports a system of universal health care through "Universal Health Vouchers" (UHV). The idea of UHV was originally proposed by Ezekiel Emanuel (Rahm Emanuel's brother) and Victor R. Fuchs (what an unfortunate name) and has been picked up by Gravel. Gravel is the only candidate so far to embrace the concept.
Plan Summary
From the Issues section of his campaign website:
Senator Gravel advocates a universal health-care voucher program in which the federal government would issue annual health care vouchers to Americans based on their projected needs. Under the Senator's plan, all Americans would be fully covered and would be free to use their vouchers to choose their own health care professional. No one would ever be denied health insurance because of their health, wealth, or any other reason. A universal health-care voucher plan will also relieve American businesses of the financial responsibility of insuring their workers while ensuring that their workers get adequate care.
Well, according to this article in the Washington Post written by Emanual and Fuchs in 2005, here's a more detailed picture of what a system of UHVs would look like:
- Employment based insurance will disappear.
- The private individual policy market will be drastically reformed, removing all pre-existing condition clauses, requiring everyone be charged the same premium for a plan, and specifying a basic set of coverage that all plans must provide.
- Everyone will receive a voucher covering the full cost of one of these basic individual health insurance policies.
- A new federal agency, the Federal Health Board (FHB) modeled after the Federal Reserve Board will regulate the private plans.
- Medicaid, SCHIP, and other federal program funding will be transfered to fund the UHVs and these programs will be phased out. People currently on these plans will purchase private plans with these UHVs.
- Medicare will be phased out. No one currently with Medicare will be dropped, but no one else will be allow to register.
- In Emanuel and Fuch's plan, UHVs will be funded by a new VAT tax. However, Gravel supports a "Fair" Tax instead.
Will everyone be covered?
Yes, they will receive a voucher covering the full cost of a basic insurance plan. Only if they're too lazy to redeem it will they not be covered.
Is it single-payer?
No.
Cost-control measures?
Emanuel and Fuchs claim that a system of UHV will eliminate inefficient government and private bureaucracies and restrict the use of newer medical technology that is not cost-effective. According to their article, this technology account for some 60% of medical inflation.