2008 Presidential Nominees Health Care Reform Platform
Comparative of NBCH's Priority Issues
Broadly, health care, particularly reform, is a partisan, ideology-driven issue. When asked about the issues that will affect their vote for president in 2008, the list of issues is similar to those the public wants to hear candidates discuss - the general economy (43%), Iraq (29%), followed by health care (21 percent). The economy is the top voting issue for Republicans, Democrats, and independents alike. Though, it is important to point out the economy and health care are intertwined issues, particularly given that health care was generally identified at the number one specific economic worry.
Just as the general population has specific health care issues and concerns that they want the presidential candidates to address, coalitions and their employers have specific issues that they will use to evaluate the candidates' strengths on health care. NBCH's Government Affairs Committee developed a list of issues that are important to coalitions and their employers and that could be used to compare and contrast the candidates. Please see the comparative chart below to help evaluate the candidates' stance on the issues. 2
The Committee determined that there are considerable economic and policy implications related to the diverse options for restructuring the health care finance system proposed by presidential candidates Senators John McCain and Barack Obama. A wide-range of policy options have been proposed to replace, modify or supplement the current health care financing system resulting in potentially significant implications for US-based employers. Based on general analysis of the candidates proposed reforms, the following are some basic conclusions we have drawn:
Employer Impact of Senator McCain's Health Reform Proposal
Employer-Sponsored Health Care
Most employers do not want to abdicate their role in providing health care benefits to their employees. They are concerned that there will be even more uninsured if there is delineation of health care benefits from compensation in a voluntary system and that employees simply will not enroll due to the direct out of pocket expenses and complexity of the system, or they will be underinsured, and therefore, underutilize prevention, wellness and health management services which would could lead to increased health care cost, absenteeism and presenteeism. According to a recent Kaiser Family Foundation survey of those who currently have employer-based insurance, 60-80% of those polled think they would be worse off if they had to purchase insurance on their own. Those that have it want to keep it. Currently, there are approximately 158 million people with employer-based health insurance.
Additionally, the employer-based health system is crucial to facilitate healthy living among employees and to control spiraling health care costs. The employer system is a real engine of innovation and change, much more so than the government could be in terms of implementing new ideas, new programs, and employers can demand changes in care more quickly based on changing workforce and employee needs. Outlook: There is growing awareness that employer-provided coverage is shrinking necessitating an alternative. But this is a radical proposal for a system that tends to adopt incremental changes. Will a tax credit be enough of a subsidy to truly help individuals and small employers? Premium costs will really need to be controlled to make access affordable.
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Employer Impact of Senator Obama's Health Reform Proposal
Employer Mandates
The play or pay approach is intended to broaden the pool of employers that would contribute to health care financing and thereby increase equity across employers by ensuring that they all pay a comparable amount for health benefits. However, play or pay primarily would impact employers that do not currently provide health insurance (i.e. small and/or new, service industry, non unionized). Faced with new or higher costs for health care benefits under play or pay, employers and employees are vulnerable in that employers my pass through the additional health financing cost to employee through lower wages, reduction in jobs and other major operation changes. Also, the expectation that providing health benefits is built into the cost of doing business may create barriers to starting or expanding a business. The play or pay model may also require employers that already offer coverage to upgrade benefits to meet new standard. There also is the concern and expense with compliance with new reporting requirements and administrative costs. Play or pay also could help the current decline of the employer-based system because employers that offer coverage now will be less likely to drop coverage when faced with a fine for doing so. But, it could also have an effect opposite than intended if the assessment is too low and grows slower than health care inflation as some will likely pay the assessment than play. This leads to decreased progress in the employer system and potentially more strain on the public health system.
Expand Public Providers
Broaden Medicare and other public programs to include the entire population. This proposal has support among those who believe it would take wasteful administrative cost and profits out of the system. An interim step might be to allow people 50 to 64 to buy into Medicare. Compared to private insurance, change and innovation is slow to Medicare/government ran programs. The other concern is that this could be the beginning of a single-payer system. In observing other countries that have a single payer system, it is not the magic potion. Typically a single payer system is riddle with inefficiency and lacks competition. In the States there still seems to be wide-spread resistance to the idea, so it may be difficult to reform our health care infrastructure around a single-payer system.
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Endorsements & Financial Contributions
2008 Presidential Nominee Comparative of NBCH's Priority Issues
| Issues |
Sen. Barack Obama (D-IL) Plan announced May 29, 2007 |
Sen. John McCain (R-AZ) Plan announced October 11, 2007 |
Value-Based Purchasing |
Require providers to report preventable medical errors and support hospital and physician practice improvement to prevent future occurrences. Align incentives for excellence in government plans (National Health Exchange, FEHBP, and Medicare & Medicaid). Providers would be rewarded for achieving performance thresholds on outcome measures, not based on the volume of services provided.
Establish an independent institute to guide reviews and research on comparative effectiveness to provide consumers and doctors with the accurate and objective information needed to make good health care decisions.
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Greater transparency regarding health care costs. Wants the public to have access to more information on treatment options and doctor records, and require transparency regarding medical outcomes, quality of care, costs and prices. Development of national standards for measuring and recording treatments and outcomes, and use technology to share information on "best practices."
Change provider payment to encourage coordinated care (i.e., pay a single bill for high quality care rather than "line-itemed" services.
Provide Medicare and Medicaid payments for diagnosis, prevention, and care coordination and bar payments for preventable medical errors or mismanagement.
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Coverage Access Model |
Overall Philosophy: Affordable and high-quality universal coverage through mix of private and expanded public insurance..
Create a new hybrid public-private plan building on the expansion of Medicaid and SCHIP. Create a National Health Insurance Exchange through which small businesses and individuals without access to other public programs or employer-based coverage could enroll in the new public plan or in approved private plans.
Related Issues:
Requirement to obtain or offer coverage:
Universal coverage, but only a mandate for children (age 25 or younger); employer mandate to provide direct coverage, help subsidize employee coverage or contribute to national plan. Specifically, employers that do not offer or make a meaningful contribution to the cost of quality health coverage for their employees will be required to contribute a percentage of payroll toward the costs of the national plan. Small businesses would be exempt from this requirement, and would receive a new Small Business Health Tax Credit that helps reduce health care costs for small businesses.
Expansion of public programs:
Expand eligibility for the Medicaid and SCHIP programs. Create a new public plan so that small businesses and individuals without access to other public programs or employer-based coverage could purchase insurance. Plan coverage would offer comprehensive benefits similar to those available through FEHBP. Coverage under the new public plan would be portable.
Premium subsidies to individuals:
Make federal income-related subsidies available to help individuals buy the new public plan or other qualified insurance.
Premium subsidies to employers:
Provide small businesses with a refundable tax credit of up to 50 percent of premiums paid on behalf of their employees if the employer pays a "meaningful share" of the cost of "a quality health plan". Provide federal subsidies to partially reimburse employers for their catastrophic health care costs if the employers guaranteed that premium savings would be used to reduce employee premiums.
Tax changes related to health insurance:
No provision
Changes to private insurance:
Prohibit insurers from denying coverage based on pre-existing conditions. Children up to age 25 could continue family coverage through their parents' plan. In market areas where there is not enough
competition, require insurers to pay out a "reasonable share" of premiums on patient care benefits. Prevent insurers from abusing monopoly power through unjustified price increases.
Require health plans to disclose the percentage of their premiums that actually goes to paying for patient care as opposed to administrative costs.
Creation of insurance pooling mechanisms:
Create a National Health Insurance Exchange through which individuals could purchase the public plan or qualified private insurance plans.
Require participating insurers to: offer coverage on a guaranteed issue basis; charge a fair and stable premium that is not rated on the basis of health status, and meet standards for quality and efficiency.
Require plans of participating insurers to offer coverage at least as generous as the new public plan.
Exchange would evaluate plans and make differences among them transparent.
State-based reform flexibility: Maintain existing state health reform plans if they meet minimum standards of the national plan. |
Overall Philosophy: Provide access to affordable health care for all by paying only for quality health care, having insurance choices that are diverse and responsive to individual needs, and encouraging personal responsibility.
Eliminates the exclusion of employer premium contributions from employees' taxable income and replaces it with a tax credit to all individuals and families to increase incentives for insurance coverage- essentially, treats employee health benefits as ordinary income with the primary goal being that Americans would become more aware of the total cost of health insurance and shop more carefully for coverage and care which would help lower demand and prices.
Provide more market-based solutions for improved access such as the ability to buy insurance across state lines to expand competition at the state level, provide incentives for HSA buy-in, individual tax credits ($2500-$5000), and contain costs through payment changes to providers, tort reform and other measures.
Related Issues:
Requirement to obtain or offer coverage:
No provision; opposes mandates for coverage.
Expansion of public programs:
Better allocation of current resources. (i.e. sign up more eligible SCHIP ; no universal mandates)
Give veterans ability to use their Veterans Administration benefits to pay for timely high quality care from providers in the best locations.
Premium subsidies to individuals:
Provide a refundable tax credit of up to $2,500 (individuals) and $5,000 (families) to all individuals and families for the purchase of insurance.
Provide income-related premium subsidies, in addition to the tax credit, to individuals enrolled in the Guaranteed Access Plan (a state and federally-supported Guaranteed Access Plan for people who are denied coverage due to pre-existing conditions. Premiums in the plan would be limited and financial assistance given to those below a certain income level)
Premium subsidies to employers:
No provision
Tax changes related to health insurance: Reform the tax code to eliminate the exclusion of the value of health insurance benefit offered by employers from workers' taxable income.
Allow individuals owning "innovative multi-year policies" that cost less than the tax credit to deposit the excess into expanded HSAs.
Changes to private insurance: Promote competition and individual choice of insurance by allowing insurance to be sold across state lines. Encourage innovative multi-year insurance products.
Creation of insurance pooling mechanisms:
Work with states to create a federally-supported Guaranteed Access Plan for people who are denied coverage due to pre-existing conditions. Premiums in the plan would be limited and financial assistance given to those below a certain income level.
State-based reform flexibility:
Support state flexibility to experiment with alternative forms of access, such as coordinated payments per episode covered under Medicaid, use of private insurance in Medicaid, alternative insurance policies and different licensing practices for providers. |
| Physician/Hospital/Insurer Performance Measurement, Reporting & Incentives
(including provider payment reform) |
Require health plans to collect, analyze and report health care quality data for disparity populations, and hold plans accountable.
Require providers to report preventable medical errors and support hospital and physician practice improvement to prevent future occurrences.
Align incentives for excellent care with both public and private insurers. Providers who see patients enrolled in the new public plan, the National Health Insurance Exchange, Medicare and FEHBP will be rewarded for achieving performance thresholds on outcome measures.
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Require development of national standards for measuring and recording treatments and outcomes, and use technology to share information on "best practices".
Change provider payment to encourage coordinated care (i.e., pay a single "bundled" bill for high quality heart care rather than individual services).
Provide Medicare and Medicaid payments for diagnosis, prevention, and care coordination and no payments for preventable medical errors or provider mismanagement.
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| Quality & Cost Transparency/Quality & Safety Improvement |
Support an independent institute to guide comparative effectiveness reviews and required reporting of preventable errors and other patient safety efforts.
Reward provider performance through the National Health Insurance Exchange and other public programs.
Require health plans to collect, analyze and report health care quality data for disparity populations, and hold plans accountable. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.
Require full transparency about quality and costs. Require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care.
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Support greater transparency regarding health care costs. Wants the public to have access to more information on treatment options and doctor records, and require transparency regarding medical outcomes, quality of care, costs and prices.
Support the development of national standards for measuring and recording treatments and outcomes, and use technology to share information on "best practices".
Change provider payment to encourage coordinated care (i.e., pay a single bill for high quality care rather than line-itemed services).
Provide Medicare and Medicaid payments for diagnosis, prevention, and care coordination but no payments for preventable medical errors or mismanagement.
Promote deployment of HIT to improve chronic disease care and to allow doctors to practice across state lines.
Support and implement, where cost effective, telemedicine and clinics in rural and underserved areas.
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| Health Care Information Technology Infrastructure (including e-prescribing & electronic medical records EMR, personal health records PHR) |
Will invest $10 billion a year over the next five years ($50 billion) to support broad adoption of standards-based electronic health information systems, including electronic health records, and will phase in requirements for full implementation of health IT.
Will ensure that patients' privacy is protected.
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Encourage greater use of information technology to reduce costs and improve care.
Support rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines.
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| Patient-Centered Care/Medical Home/ Care Coordination |
Support program implementation and encourage team care that will improve coordination and integration of care for patients with chronic conditions. |
Support coordinated health care with providers collaborating to produce better outcomes at a lower cost and to make every single provider accountable and responsive to the patients' needs. Does not specifically mention primary care providers.
Change provider payment to encourage coordinated care (payment by episodes of care versus payment for individual services).
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| Population Health Improvement/ Chronic Illness Prevention & Management |
Expand funding to improve the primary care provider and public health practitioner workforce, including loan repayments, improved reimbursement, and training grants.
Expand funding to improve the primary care provider and public health practitioner workforce, including loan repayments, improved reimbursement, and training grants.
Support preventive health strategies including initiatives in the workplace, schools, and communities.
Support strategies to improve the public health infrastructure and disaster preparedness at the state and local level.
Wants to address health disparities, promote and strengthen preventive care and chronic disease management in public health programs. Wants to find the causes of health disparities by addressing differences in access to health coverage and promoting prevention and public health, both of which play a major role in addressing disparities.
Wants to help the medical system to eliminate inequities in health care through quality measurement and reporting, implementation of effective interventions such as patient navigation programs, and diversification of the health workforce.
Require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs to improve quality of care, and give doctors better information and lower costs.
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Support federal research related to science-based care and cure of chronic disease.
Promote education of children about health, nutrition, and exercise.
Support public health initiatives to stem obesity and diabetes and deter smoking. Specifically focused on smoking cessation programs. Wants to work with employers and insurance companies to promote availability of such programs.
Government should lead the way and emphasize prevention, early intervention, healthy habits, new treatment models, new public health infrastructure and the use of information technology to reduce health care costs and improve population health status.
Dedicate more federal research to curing chronic disease and helping patients with chronic diseases.
Supports coordinated care, with providers collaborating to produce the best health care outcomes at a lower cost. Believes Americans should pay a single bill for high-quality care and make all providers accountable and responsive to the patients' needs.
Government should promote greater access to address simple, immediate health care needs by way of walk-in clinics in retail outlets.
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| Clinical Effectiveness Research (efficiency & effectiveness) |
Supports an independent institute to guide comparative effectiveness reviews and required reporting of preventable errors and other patient safety efforts. |
Supports federal research related to science-based care and cure of chronic disease. |
| Medicare/Medicaid Program Reform |
Pay Medicare Advantage plans the same as regular (traditional) Medicare.
Reimburse Medicare/Medicaid providers based on improvement of quality of care provided, not based on volume of services.
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Reform the current government fee for service payment system to cut costs replaced by a system of bundled payment for episodes of care and payments based on outcomes.
Compensate providers for diagnosis, prevention and care coordination.
Should not pay Medicaid and Medicare for preventable medical errors or mismanagement. Medicare payment reform should drive broader changes in the health care system
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| Pharmacy Industry Reform |
Lower health care costs, in general, by increasing competition in the drug markets.
Lower prescription drug costs, estimated to be the second-fastest growing type of health expense, by allowing Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S.
Repeal the ban that prevents the government (i.e Medicare) from negotiating with drug companies for low pricing.
Increase the use of generic drugs in Medicare, Medicaid, and FEHBP and prohibit drug companies from keeping generics out of markets
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Supports greater competition to U.S. drug markets through safe re-importation of drugs and faster introduction of generic drugs. |
| Support for Small Business |
Create a Small Business Health Tax Credit to provide small businesses with a refundable tax credit of up to 50 percent on premiums paid by small businesses on behalf of their employees. The goal of this strategy is to provide a strong incentive to small businesses to offer high quality health care to their workers and help improve the competitiveness of America's small businesses. |
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| Consumer Incentives/Tools |
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Encourage and expand Health Savings Accounts (HSAs). Believes that when consumers are better informed about medical choices, they are more capable of making their own decisions about their health care. HSAs take an important step in the direction of putting consumers in charge of what they pay for. |
| ERISA Preemption |
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| Family Medical Leave Act Reforms |
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| Cost Containment |
*No substantive plan to reduce costs.
Invest $50 billion toward adoption of electronic medical records and other health information technology.
Promote insurer competition through the national Health Insurance Exchange and by regulating the portion of health plan premiums that must be paid out in benefits.
Improve prevention and management of chronic conditions.
Initiate policies to promote generic drugs, allow drug reimportation, and repeal the ban on direct price negotiation between Medicare and drug companies.
Pay Medicare Advantage plans the same as regular (traditional) Medicare.
Require hospitals and providers to publicly report measures of health care costs and quality.
Promote and strengthen public health and prevention.
Reform medical malpractice while preserving patient rights by strengthening antitrust laws and promoting new models for addressing physician errors.
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*No substantive plan to reduce costs.
Adopt malpractice reforms that limit frivolous lawsuits and excessive damages and provide safe harbors for practice within clinical guidelines and safety protocols.
Promote competition among providers by paying them only for quality and promote use of alternative providers (e.g., nurse practitioners) and treatment settings (e.g., walk-in clinics in retail outlets).
Invest in prevention and care of chronic illnesses.
Increase competition and reduce administrative overhead costs of private insurance by permitting sale of nationwide insurance (i.e., not regulated by the states).
Require drug companies to reveal the price of their drugs; allow re-importation of drugs; and encourage faster introduction of generics and biologics.
Provide consumers with more information on treatment options and require provider transparency regarding medical outcomes.
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| Financing Reform Plan $$ |
Campaign estimates cost of the health care reform proposal to be between $50 to $65 billion a year when completely phased-in. Expects much of the financing to come from savings within the health care system. Additional revenue to come from discontinuing tax cuts for those with incomes over $250,000.
According to the Tax Policy Center (TPC), Obama's reform plan would raise the national deficit by $1.6 trillion but would allow 18 million more people to become insured in just one year, and 34 million by 2018.
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Not yet specified, although campaign indicates that cost containment measures would make insurance more affordable.
According to the Tax Policy Center (TPC), McCain's health plan would raise the deficit by $1.3 trillion over ten years. But McCain's plan will only reduce the number of uninsured by about 5 million in five years.
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1 Kaiser Health Public Opinion Spotlight April 2008
2 Please note that this is an ever-evolving document. To ensure content is timely and current, every effort will be made update it on a weekly basis through the 2008 presidential election cycle
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