Edwards Goes First on Health Care

Edwards started his campaign talking more of starting a movement and seemed to be avoiding specifics on the issues. He deserves credit for being the first candidate in this cycle to provide some specifics as to what he intends on health care. (Of course Hillary beat him by several years if we can consider her previous proposal to be her current plan). I’ve delayed commenting for a day and still cannot decide whether to give it a thumbs up or thumbs down. There are two problems in making such a decision. First, there are many areas where the posted description remains vague and more information is needed. Secondly, a problem with health care reform is that there are potential objections to any plan. There is no perfect solution, but something must be done. Before dwelling on the negatives of one plan it may be necessary to compare the plans of all the candidates, should the others also release plans, to see which provides the most good with the least negatives. Therefore I’ll refrain from making a decision on the plan for now and just comment on some aspects.

Edwards would continue to base insurance on employer coverage including a mandate to either provide coverage or pay the cost of covering them. He claims that his plan would make it easier for employers to provide coverage due to lower health care costs. There’s no mention of how much employers would have to pay or what provisions there are for smaller businesses which would have difficulty affording an added expense.

Edwards proposes to expand Medicaid and SCHIP to cover all adults under the poverty line and all children and parents under 250 percent of the poverty line (about $50,000 for a family of four). I would hope that a move towards universal coverage would also lead away from the current system where some are covered by inferior programs such as Medicaid. Unless this is accompanied by a marked increase in payment and decrease in bureaucratic hassle currently seen with Medicaid it is questionable whether all these new people with Medicaid would even be able to find physicians willing to see them.

The measure which might help the most people who are currently poorly served by the private health insurance industry would be to change to community rating require coverage regardless of preexisting conditions. This would help prevent the insurance companies from selling insurance to the healthy and avoiding coverage of those who actually need coverage. He would also require that all health plans offer preventative care. This would save money in the long run but it would be years before the savings would actually be seen and would actually increase health care costs in the short term. We cannot count on such savings to reduce the burden of paying for health care insurance by employers.

Edwards would create new Health Markets to provide choices of coverage for employers and individuals. The most interesting feature of the plan is the inclusion of a government plan based upon Medicare in each Health Market. The government plan would compete with the private plans and could wind up being a back door approach to achieving a single payer plan if the government plan continues to be more cost effective than private insurances as Medicare currently is. For employers, providing coverage would be more like making a Social Security or Medicare payment for employees to the Health Markets which would be responsible for negotiating prices and many of the administrative burdens now faced by businesses.

Edwards includes many ideas for better utilization of health care dollars such as using computer technology more effectively and stressing evidence based medicine. It isn’t clear that such measures will really lower prices enough to make coverage affordable for small businesses and individuals in the short run. He also recommends payment to physicians based upon results. In principle this could be a good idea but in practice they would need to do a much better job than is currently being done to measure quality. Currently I find such reports which claim to evaluate quality from HMO’s to be packed with misinformation. For example, reports on the quality of care provided to my diabetic patients typically include several non-diabetics, misses many of the tests which were done, and the reports even include people who are not my patients, such as people I might have only read an EKG on for the local hospital. Of course it is possible that the problems could be fixed, but an accurate method of assessing quality care would be necessary before this could be considered for use for reimbursement.

One surprise is that Edwards didn’t mention malpractice reform. While Republican typically exaggerate considerably the cost savings this could result in, failure to mention this will only reinforce the biases against Edwards due to his previous career in malpractice law.

Politically Edwards faces several obstacles. The most significant is that the media (such as here and here) is concentrating upon the tax increases necessary for funding the plan without consideration of the savings from decreased health insurance costs.

Update: Further discussion added here.

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