Analysis of the Candidates’ healthcare Proposals

by Stephen E. Beller, PhD [email / bio]

Contributors:
Barry Carol
Sabatini Monatesti

Latest Update on 1/25/08: View updates here.
(Check back for future updates)

Introduction

This site systematically analyzes the presidential candidates’ healthcare proposals and matches them to the wants and needs to 18 groups of voters. Several resources were used to compile this information, with the bulk coming from documents available on the Kaiser Family Foundation's Health08.org website at http://www.health08.org/sidebyside.cfm and on the Huffington Post website at http://www.huffingtonpost.com/susan-blumenthal/us-presidential-candida_b_79371.html.

In order to assure accuracy, please contact Dr. Beller to report any errors or omissions.

Describing the Proposal Selection Chart
Identifying the Best Candidates Based on the Proposal Selection Chart
Viewing the 18 Options in the Proposal Selection Chart

End Note 1: Candidates’ Quality Improvement strategies
End Note 2: Candidates’ Cost Control strategies
End Note 3: Determining which is better: A publically-funded Universal Healthcare System with an option for Private Insurance OR a Single-Payer program without any Private Insurance
End Note 4: Determining if it necessary to increase taxes in order to fund a publically-funded universal healthcare program

Examining how the Best Candidates were selected from the Proposal Selection Chart

Viewing the Quality Improvement and Cost Control Strategies Summary Chart
Matching the best candidates to the 18 voter groups

Using the Candidate Comparison Grid to compare the details of the proposals

Proposal Selection Chart

After analyzing the details of each Presidential candidate’s healthcare proposal, the best proposal appears to depend on one’s current health insurance plan, level of wealth, and priority for assuring good healthcare for all. This is reflected in the Proposal Selection Chart.

dESCRibing the Proposal Selection Chart

The Proposal Selection Chart provides a logical way to choose a candidate’s proposal based on three factors:

The first factor is one’s Current Health Plan. Located in the first column of the chart, it identifies three typical health insurance scenarios:

People who believe (a) they have good coverage (be it publically funded or private insurance), (b) they won’t ever lose it and (c) it keeps their health-related expenses low.
People who believe they have good coverage and they won’t ever lose, but their health-related expenses are too high.
People who (a) don’t have insurance, or (b) they believe their insurance policy is poor or inadequate, or (c) they have a high risk of losing their coverage and not getting adequate, affordable insurance in the future.

The second factor is Wealth Level. Located in the second column of the chart, it identifies three levels of personal wealth: High, Middle and Low.
The third column is Universal Healthcare Priority. Located in the third column of the chart, it identifies whether a person places a High or Low Priority on assuring that everyone gets good healthcare. High Priority means the person wants a Universal Healthcare System (UHS), which may be a federally-funded system based on the Federal Employees Health Benefits Program (FEHBP-UHS) that exists along with private insurance options, or a Single-Payer Universal Healthcare System (SP-UHS) that does not allow private insurers.

The forth column—Proposal Most Likely to be Chosen—identifies the type of healthcare proposal a person is likely to chose based on the factors in the other three columns. There are 18 voter groups.

In addition, the End Notes section includes other charts identifying how the candidates strategies for dealing with (or not dealing with) healthcare quality and cost control issues, as well as identifying important strategies that no candidate proposes.

Return to Table of Contents

Identifying the beSt Candidates

Each candidate’s proposal was analyzed based on the needs and desires of the 18 voter groups. This analysis considered whether the candidate proposes a universal healthcare system (UHS). It also took into account the number of strategies proposed to improve healthcare quality and control costs. While not all the strategies are equally important, the total number of strategies proposed gives some indication of how much attention a candidate is paying to these issues. Based on this analysis, the following identifies the best candidates:

The candidates most concerned with improving the quality and controlling the costs (i.e., increasing the value) of healthcare are: Clinton, Obama and McCain.
Voters who want good care for all are willing to do what it takes—including paying increased taxes, etc.—to support a publically-funded UHS. Candidates who want a Federal Employees Health Benefits Program UHS (FEHBP-UHS) and want to keep private insurance as an option are: Biden, Clinton and Obama. Since Kucinich has dropped out of the race, no one is proposing a government-run Single Payer UHS (SP-UHS). Choosing between these two options is discussed in the end notes [3].

If an FEHBP-UHS is desired, then Clinton and Edwards are the best choices because they also more focused on increasing care value, with Obama coming in second.
If an SP-UHS is desired, then Kucinich was the only choice. Note that his plan (HR 676) was also the most detailed (has the greatest specificity), which means it may be the most credible. But since he’s no longer running, it’s off the table.

On the other hand, any Republican is a suitable choice for voters who (a) are not concerned about the care others receive (they aren’t interested in good care for all) and (b) are confident they will always have excellent insurance, or can afford to pay for the care they need out-of-pocket if they lack adequate insurance. Choosing between Republican candidates would likely be based on their strategies for:

Minimizing taxes and reducing personal health-related expenses
Increasing healthcare value (cost-effectiveness), in which case McCain is probably the best choice since he proposes the most strategies of all Republicans for improving quality and controlling costs (as well as being the only Republican addressing the health need of veterans through the VA).

Note, however, that there are significant gaps in every candidate’s proposal. It would be useful to know how what it would require to (a) evaluate all the quality improvement and cost control strategies described in this document and to (b) implement the effective ones efficiently.

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tHE Proposal Selection Chart: The 18 Options

Note that end notes contain important supplemental information and can be access by clicking the end note links, which are indicated by a number in brackets: [#].

Assumptions: (a) anyone with existing health problems or risks factors has greater urgency for insurance coverage and (b) anyone with knowledge about the quality problems in our current healthcare system (see this link and this link) would want to implement strategies for improving care quality [1].

Current Health Plan	Wealth Level	UHC Priority	Proposal Most Likely to be Chosen
Ÿ Good insurance coverage Ÿ Low out-of-pocket cost Ÿ Low risk of ever losing the coverageⁱ	High	High priority	(1) FEHBP-UHSⁱⁱ + Private Insurance
	High	Low priority	(2) Keep own insurance; Reject tax increase and approve tax breaks (tax credits, deductions) for self; Controlling care cost is unimportant
	Middle	High priority	(3) FEHBP-UHSⁱⁱ + Private Insurance
	Middle	Low priority	(4) Keep own insurance; Reject tax increase and approve tax breaks (tax credits, deductions) for self; Controlling care cost is not very important
	Low	High priority	(5) FEHBP-UHSⁱⁱ + Private Insurance
	Low	Low priority	(6) Keep own insurance; Tax issue less important; Control care costs [2]
Ÿ Good insurance coverage Ÿ High out-of-pocket cost Ÿ Low risk of ever losing the coverageⁱ	High	High priority	(7) FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3]
	High	Low priority	(8) Keep own insurance; Reject tax increase and approve tax breaks (tax credits, deductions) for self; Control care costs [2]
	Middle	High priority	(9) FEHBP-UHSⁱⁱ+ Private Insurance or SP-UHSⁱⁱⁱ [3]
	Middle	Low priority	(10) Keep own insurance; Reject tax increase and approve tax breaks (tax credits, deductions) for self; Control care costs [2]
	Low	High priority	(11) FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3]
	Low	Low priority	(12) Keep own insurance; Tax issue less important; Control care costs [2]
Ÿ No insurance OR Ÿ Poor or Inadequate insurance coverage OR Ÿ High Risk of losing the coverage	High	High priority	(13) FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3]
	High	Low priority	(14) Keep own insurance: If lost or inadequate, purchase new private insurance or pay out-of-pocket for needed care; Reject tax increase and approve tax breaks (tax credits, deductions) for self; Control care costs [2]
	Middle	High priority	(15) FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3]
	Middle	Low priority	(16) (a) If no insurance or it’s inadequate, then FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3] or (b) If current insurance is adequate, then Universal Public Program in case current insurance is lost or inadequate; Don’t reject tax increase if necessary to fund the FEHBP-UHSⁱⁱ or SP-UHSⁱⁱⁱ [4]; Control care costs [2]
	Low	High priority	(17) FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3]
	Low	Low priority	(18) (a) If no insurance or it’s inadequate, FEHBP-UHSⁱⁱ + Private Insurance or SP-UHSⁱⁱⁱ [3] or (b) If current insurance is adequate, support FEHBP-UHS in case current insurance is lost or inadequate; Don’t reject tax increase if necessary to fund the FEHBP-UHSⁱⁱ or SP-UHSⁱⁱⁱ [4]; Control care costs [2]

ⁱ Among those who are without health insurance, at least 80% had it but lost it, so the risk may be greater than most people realize (see this link). Primary causes include job loss or change, employers dropping coverage for their employees/retirees, and serious illness. Even the long-term fiscal viability of Medicare is questionable (see this link and this link).

ⁱⁱFEHBP-UHS=Federal Employees Health Benefits Program Universal Healthcare System
ⁱⁱⁱ SP-UHS=Single-Payer System Universal Healthcare System

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Identifying the Candidates’ pROPOSALS Best Suited for Each of the 18 Options

Determination of the best proposals for the 18 options was done by:

Matching the 9 High Priority Universal Healthcare options with candidates whose proposals support a FEHBP-UHS or SP-UHS.
Since Quality Improvement is relevant to all 18 options, selecting the candidates who have a strong focus on improving quality by virtue of the number of strategies in their proposals that address quality improvement, as per the Quality Improvement and Cost Control Strategies Summary Chart below.
Matching the 16 options in which Cost Control is important with the candidates who have a strong focus on controlling costs by virtue of the number of strategies in their proposals that address cost control, as per the Quality Improvement and Cost Control Strategies Summary Chart below.

Quality Improvement and Cost Control Strategies Summary Chart

This Quality Improvement and Cost Control Strategies Summary Chart is based on data from the Quality Improvement and Cost Control Strategy Grids at End Note 1 and End Note 2, respectively. An analysis of these data indicate that the candidates most serious about improving quality and controlling costs are Clinton, Obama, Richardson and McCain; with Clinton and Kucinich scoring highest.

Note, however, that there are significant gaps in all candidates’ proposals.

Total number of strategies in candidates’ proposals
are in last two rows

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QUALITY IMPROVEMENT Strategies

9ⁱ

COST CONTROL Strategies

8ⁱⁱ

ⁱ Kucinich given 1 Quality Improvement Strategy point for not needing private insurance incentives and disincentives.

^{i i} Kucinich given 3 Cost Control Strategy point for not needing private insurance incentives.

Matching The Best Candidates to each of the 18 Options

Following are candidate’s proposals that are best suited to each of the 18 voter groups (best candidates in bold):

1, 3, 5: Clinton, Obama
7, 9, 11, 13, 15, 16, 17, 18: Clinton, Obama
2, 4, 6, 8, 10, 12, 14: Huckabee, McCain

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THE Candidate Comparison Grid: cOMPARING THE cANDIDATES’ pROPOSALS

The grid below shows details of each candidate’s proposal.

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Universal Healthcare System (UHS)

· Government-Run Single-Payer System (SPS)

· Government-Run Federal Employees Health Benefits Program (FEHBP)

· Health Markets

· Vouchers

Allow Private Insurers

Mandates (individual and/or employer requirements)

· Requirement for Individuals to receive coverage
(Osama – Only children required)

· Requirement for (large) Employers to provide coverage or help their employees purchase it

Creation or Expansion of Public Programs

· Support the creation of new public programs

· Expand existing public programs

· Replace Medicare and Medicaid with new public programs

Insurance Pooling (Community Ratings)

Tax Credits/Subsidies/Deductions for Individuals/Families

ðTax Credits/Incentives

· Tax credits

· Tax incentives

ð Subsidies: Premium Payments Based on Income

· Sliding scale/subsidized premiums

ð Tax Deductions

· For individuals without employer-based coverage

ð Tax Code Changes

· Eliminate bias toward employer-sponsored health insurance

· Permit full deductibility of qualified medical expenses

· Eliminate federal tax incentives for “bare-bones, high-risk plans.”

Tax Credits/ Subsidies/Deductions
for Businesses

· Tax Credits

· Subsidies

· Sliding Scale Premiums

Health Savings Accounts

· Have simpler regulations

· way to encourage people to limit the use of services

· Allow expansion

· Eliminate minimum HSA deductible requirements

State Flexibility (i.e., states may offer their own plans)

· States may band together to offer same type of regional public plan

· Give states block grants

· Give states flexibility and encouragement to experiment

Changes in Private Insurance

· No Discrimination for Pre-Existing Conditions

· No Discrimination for At-Risk Conditions

· Coverage is Guaranteed Issue and Guaranteed Renewable; Portability Across Jobs

· Insurers Must Meet Minimum Loss Ratio; Must Pay Reasonable Share of Premium on Care Benefits

· Use of Out-Of-Network Providers in Emergencies

· Older Children can Continue Family Coverage through Their Parents’ Plan

· Prevent Abuse of Monopoly Power through unjustified price increases

· Permit Individuals to Purchase Insurance Across State Lines

· Encourage Innovative Multi-Year Insurance Products

· Provide Federal Incentives for States to Deregulate & Reform Health Insurance Markets

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Financing & Payments

ð Total Annual Cost of Initiative (estimated)

· Equal to current spending less $387 billion/year savings

· $50-65 billion

· $104-110 billion

· $110 billion

· $90-120 billion

ð Finance with Revenue from Limits/Roll-Back of Tax Exclusions and Cuts

· $54 billion in revenue from limiting the tax exclusion for employer-paid health insurance and discontinuing tax cuts for those with incomes over $250,000

· additional revenue to come from discontinuing tax cuts for those with incomes over $250,000

· finance the plan by rolling back tax cuts for those earning more than $200,000 a year

· reduce corporate welfare and reverse 2001 and 2002 tax cuts for additional $351 billion revenue

ð Finance with Savings

· Anticipates that savings from the voucher program can finance universal coverage without additional costs

· Expects much of the financing to come from savings within the health care system

· Estimates that savings to the government will result from streamlining administration, reinvesting money now spent on uncompensated care, and investing in prevention and chronic disease management should be sufficient to cover the required costs

ð Finance with Insurance Premiums

· With a combination of employer and individual/family premiums

ð Finance with New or Increased Taxes (Payroll, Income, Investment Taxes)

· Increase personal income taxes on the top 5 percent income earners; Institute a excise tax on payroll and self-employment income; Institute a small tax on stock and bond transactions; Payroll Tax (3.3% additional on employer/employee) to generate $538 billion; Stock Transfer Tax (0.25% on seller & buyer) to generate $150 billion revenue; Tax Surcharge: 5% on richest 5% of taxpayers annual income between $184,000 and $279,999; 10% on richest 1% annual income of $280,000+ to generate $351 billion

· Existing sources of federal revenue for health care would be transferred to the new public program; appropriations for existing programs for uninsured and indigent will be transferred and appropriated

ð Finance with Other Revenue Streams

· Including those that result from ending the war in Iraq and by recapturing existing uncompensated care subsidies

ð Finance by Redirecting Existing Subsidies

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Improving the Quality of Care

· Transparency of Quality to support consumers’ decisions

· Clinical Health Information Technology

· Use Case Management

· Coordinate/Integrate Care and Provider Communications

· Promote Evidence-Based Care/Best Practices

· Promote/Support/Fund Medical Research

· Develop and Use Quality Metrics; Quality Control Oversight

· Deploy Performance Incentives and Disincentives for Providers

· Deploy Performance Incentives and Disincentives for Patients

· Deploy Performance Incentives and Disincentives for Insurers

· Increase Market Competition among Insurers

· Reduce Errors and Increase Safety

· Promote Consumer Literacy/Education

· Support Medical Homes

· Utilize Telemedicine

· Reduce Healthcare Disparities

· Free Choice of Provider

· Mental Health Parity

· Prepare for Public Health Threats

· Streamline FDA Drug Approval Process