I know there was a short diary on Elizabeth Edward's remarks but I wanted to specifically address some things she said last night as they are deserving of much discussion.
I watched Elizabeth Edwards on Countdown with Keith Olberman last night and her statements were misleading and extraordinary all at the same time. I want to start to say that I have always been a big fan of Elizabeth Edwards.
I want to comment on three things she said in the interview:
"A mandate is an essential ingredient in a universal health plan."
"We really care less about the human being who occupies the office than we do that that human being embraces these policies."
"If John McCain wants to endorse a universal health care plan, tomorrow, you know, I'll say that is a great plan."
It is hard to even know where to start. So I will take each one at a time.
But first, during the interview, Mrs. Edwards asked why the media does not do a better job of explaining the candidates’ health proposals to the American people? The reason the media does not try to explain the health plans in any detail is because our health care system has evolved incrementally over the last 80 years with a mix of private and public benefits that is so complex as to be almost incomprehensible. But I will do my best.
1. A “mandate” is an “essential” ingredient in a “universal” health plan"
The first point to make is that both Senators Kennedy and Kerry have said that a mandate will never pass the Congress and that the idea is dead on arrival. The Democrats in Congress will write a universal health care proposal and it will not include a mandate. SO in fact, the point is a moot one.
Mandates: The purpose of an individual mandate to purchase health insurance is to prevent "free-rider" in the system.
Free riders: In the US, free-riders are predominately young, healthy people who can afford health insurance and choose not to buy it. The largest group of uninsured in the US is the 19-29 age group. However, many of these young people are not free riders as they literally do not have any available or affordable health insurance options. The "free-rider" designation only applies to those who COULD afford it but don't buy it because they think they don't need it. It does not include those for whom no employer insurance is provided and no private insurance is affordable.
Who is this lost group? In most states, when adult children turn 19, they are no longer eligible for coverage as dependents under their parents’ health insurance policy. The age limit for dependent coverage varies by state and ranges from 19-30. Obama’s proposal is the only one to require that insurers extend eligibility to young adults to remain on family coverage up to age 25. This will solve a large part of the problem with the so-called “free-riders”.
The reason policy makers worry about "free riders" is that if a large group of healthy people opt out of the “pool”, leaving the sicker and more expensive people in the pool, it raises the costs for everyone.
But there really is no such thing as "free care". Conservatives like to argue that anyone can get care in an emergency room, but the care is often delayed and inadequate and very expensive. It is hardly "free."
Adverse selection also compounds the problem, as those with health care needs are the most motivated to buy insurance when it first becomes affordable. This is why it is important to have the pool be initially available only to those who are not in a government program. Both the Clinton and Obama plans preserve the Medicaid and Medicare programs, where those with disabilities and the elderly are covered. These are in fact, the most expensive groups to insure and maintaining them in separate pools is probably the single most important thing we can do to protect against adverse selection in the general pool. We want the pool to grow as big and as quickly as possible. I dare say that Obama has established a network of volunteers and supporters who would be willing to reach out to all of their neighbors and friends and coworkers and relatives and get them to sign up.
Rather than threaten to punish people if they don’t get health insurance, why don’t we recognize those who enroll for being the true patriots they are, contributing to the greater good of the community, to the public welfare, and at the same time, benefiting as an individual. I think the American people are probably more ready to help the government implement a universal coverage program than at any other time in my lifetime.
And if the plans can get to 95% coverage and the pool includes all workers in small firms, all people who currently buy in the individual market, and most of the people who are presently uninsured, the risk pool will enroll millions of Americans and will not include those who are the highest risk and costs (disabled and elderly). The pool will be made up primarily of working age people and their families. Concerns over adverse risk in the pool, as it is designed, are exaggerated and adding the last 5-10 million Americans, who are most likely to be young and healthy, will only help to reduce the costs of the entire pool.
What about the 15 million? Senator Clinton has accused Obama of leaving 15 million people uninsured. The truth is that this estimate was made based on an analysis of NEITHER of their plans. It is the estimate that economists make for how far comprehensive incremental reforms, which is essentially what both of their plans are, can get us towards universal coverage. And that number is estimated to be 95-96% of the population would be covered. Since there are 303 million Americans, this translates into about 15 million people (5% of 303 million) who remain uninsured. It is not that they are left out or excluded but they are estimated to include the "free riders" and the people who live in the shadows who will be very hard to reach under any plan (i.e., those with no link to employment or the tax code such as the homeless, seriously mentally ill, the chronically unemployed, and people who have an undocumented worker in their family and are afraid to sign up for a government sponsored program). Mrs. Clinton wrongly assumes that her mandate will force these last 15 million to buy coverage. Therefore, the argument goes, her plan covers 15 million more than his. But a mandate will not force all 15 million people to buy coverage. There will be millions of people who do not enroll under the Clinton plan, as well.
Experience in Massachusetts, with auto insurance in the US, and with universal health care in Netherlands suggests that mandates are not perfectly enforceable and will fail to get to 100% of the population covered. Massachusetts has had to exempt 20% of the uninsured from their mandate because there are no affordable policies for them to buy. States that mandate the purchase of car insurance find that 15-20% of drivers remain uninsured. And in the Netherlands, where they have a universal system where enrollment Is automatic and there is no premium, they can only get to 98% enrollment. They adopted a mandate to try to get the last 2%, but they are still at 98%. If a mandate only covers 80% of the uninsured, then Senator Clinton’s plan leaves out 9-10 million (20% of 47 million).
But the truth is no one knows how many people will enroll in either plan and they both will require tremendous outreach and ease of enrollment to get as many Americans as possible enrolled.
The Undocumented: Finally, NEITHER of their plans is truly universal as they both exclude undocumented workers and their families who live and work and go to school in our communities. We will still need public health services and safety net medical care system to provide care for these people, as well as those who remain uninsured, even under a mandate.
Point-of-Care Enrollment One mechanism that is likely to be even more effective in maximizing enrollment than an individual mandate is what is called point-of-care enrollment. When you arrive at a clinic or hospital or doctor’s office or emergency room, you will be offered enrollment in health insurance as part of your intake process, with information on what your choices are and how much your monthly premium would be based on your household income. Individuals could be told that they have a choice – to enroll in insurance or sign a form taking full responsibility for the costs their care. This would eliminate any notions of a “free” system and provide an immediate incentive to get coverage at the point of care.
On average, 67% of the uninsured use health care each year. Thus, over a two year implementation time frame, approximately 90% of the uninsured will have sought care and given the opportunity to enroll. This a much more compassionate and efficient and effective approach to maximizing enrollment than putting people in the hands of the IRS for monitoring and enforcing their health coverage.
The Bottom Line: A mandate will initially enroll more people than a plan without one, but it is neither necessary nor sufficient for achieving universal coverage.
2. “We really care less about the human being who occupies the office than we do that that human being embraces these policies."
This is extraordinary. She is saying that it doesn’t matter who the person is who is the President of the United States. She is saying that all that is important is that they agree with her on the importance of mandates and their essential role in achieving universal coverage.
Really? We don’t care about the human being? You mean the human being who will be the President of our nation in January 2009, who will be the Commander in Chief of our Armed Forces, the one person who can set the policy agenda in Washington and take this country in a new and positive direction? It doesn’t matter if the person is a person of integrity? It doesn’t matter if the person is honest with the American people? It doesn’t matter what the person’s values and vision are? It doesn’t matter? Is she saying it doesn’t matter what kind of campaign they have run or what their positions are on other issues? Really?
So is she saying that even if John McCain proposed a health insurance plan that had a mandate to buy a high deductible health plan in the private individual market, without any new regulation of that market so that they could still underwrite and use pre-existing limits and exclusions, that she would support THAT plan?
And then she did it. She said:
3. “If John McCain wants to endorse a universal health care plan, tomorrow, you know, I'll say that is a great plan.”
So what makes a health plan a great plan and what makes a health plan a universal plan is a government mandate to force people to buy coverage and punish them with penalties for remaining uninsured?
So it doesn’t matter who is the President of the United States, as long as they force everyone to buy health insurance, they meet the test for Commander in Chief?
WOW.
Here is probably the most important part of this diary.
Not all universal coverage is created equally.
Universal means many things.
Elizabeth Edwards seems to be defining "universal" to mean that every person in the country buys health insurance or pays a fine. Under a mandate, the government will force all Americans to purchase coverage. Surely Mrs. Edwards doesn't mean that those with incomes below 100% of the federal poverty guideline should have to "buy" coverage. Clinton’s plan is clear in maintaining the provisions of Medicaid that require no premiums for persons below a certain income. I think she “misspoke”.
Obama on the other hand defines “universal” as everyone having affordable, comprehensive health care coverage that gives them access to high quality care.
Any universal coverage plan that is concerned only about getting everyone in the pool is completely inadequate. In fact, I would argue that what is essential to universal coverage has little to do with forcing people to enroll.
What is important to achieving universal coverage are the following:
Affordability – You can’t force people to buy something they cannot afford. The main reason most Americans don’t have health insurance is not because they do not want it for themselves and their families. It is because they can’t afford it. If we offer people affordable coverage, most will elect to purchase it.
Should we design policy for the 95% who desperately want affordable comprehensive coverage or for the 5% who don’t? Obama’s first priority is to get affordable coverage to the 95% who want it, without excluding anyone. Affordability also means setting limits on out of pocket expenditures, not just on premiums, but on overall costs, on an annual and lifetime basis, to protect everyone from catastrophic costs.
Comprehensive coverage: Requiring Americans to buy cheap but lousy health insurance coverage will not solve our problems, but will exacerbate them further. Individuals need coverage for a comprehensive set of benefits that will promote their health, prevent disease, disability, and premature death, provide effective treatments when they are ill or injured, and that will manage their chronic diseases to prevent complications, keep them out of the hospital, and maximizing quality of life.
Anything short of comprehensive coverage is not universal coverage.
Quality Health Care: The US faces a crisis in the relatively poor quality of health care Americans receive relative to what they need and would benefit them most. Our rates of errors are too high. The chances of getting an infection in the hospital are too high. The variations in the quality of care that is provided across doctors, medical groups, hospitals, and health systems is enormous. The use of information technology and electronic medical records is limited and not standard practice. The use of specific treatments or drugs in an area often bears no relationship to the underlying health status of that population. And efforts to measure, assess, monitor, and improve quality are still in their infancy and under development. But the point is that we will not truly have universal coverage until the coverage translates into getting the care you need when you need it. This means that the care that is delivered and purchased through your health insurance is safe, timely, effective, efficient, equitable, and patient centered.
Access to services: It is also likely that there will be a shortage of primary care providers when both of these plans are implemented. It takes at least 2 years to train a masters level nurse practitioner and at least 6 years to train new primary care physicians. And there is likely to continue to be a shortage of health care providers and facilities in rural areas. Universal coverage will mean little if the health care system does not have the capacity to meet the needs of the population.
Health care is a human right. Probably the one thing the United States could do to move boldly in the direction of universal coverage would be to formally recognize health care as a human right.
Both Senators Obama and Clinton have said publicly that they believe that health care is a human right. But only Senator Obama's plan is designed within the framework of extending rights to the population.
The government's role in extending basic rights to people is: 1) to make sure that people's rights are not denied, and 2) to enable people to get their rights met. This is what Senator Obama's plan does.
Senator Clinton, however, sees the role of the government in health care as a coercive and punitive force that requires that people get their rights met buy requiring them to purchase it and then punishing them if their rights are not met. Neither Clinton’s nor Edward’s policies reflects an understanding that health care is a human right to which all Americans should be entitled
Finally, I think the biggest difference in their approach is how they view the American people.
Senator Obama is constantly reminding us that the American people are a good and generous people. He trusts them to make good decisions for themselves and their families when confronted with reasonable choices. He believes that because most Americans want to do the right thing and have health insurance coverage for themselves and their families, if he makes care affordable, then every single person who wants coverage will have it and no one is excluded. As a constitutional scholar, Senator Obama respects individual liberty and autonomy and soundly rejects the idea of mandating that adults buy a government product. Americans want choice, and Obama respects their right to choose.
Senator Clinton's policy on the other hand seem to reflect her distrust of the American people. She thinks that they want to avoid their responsibilities and will chose to remain uninsured even when offered affordable comprehensive coverage. She believes that the American people will not do the right thing unless they are coerced and forced to do it and she intends to literally punish those who remain uninsured.
It is true that the basic structure and framework of the Obama and Clinton health care proposals are similar. But how they would implement them, the faith they have in the American people, and their use of the government in implementing their plans, reflect deep philosophical differences that are representative of how they will approach the Presidency.