According to the Democratic presidential candidates, the current U.S. health care system ought to focus more than it does on disease prevention to save billions of dollars in treatment costs.
That’s what their health policy advisors said at an October 23 forum sponsored by the Partnership to Fight Chronic Disease and Congressional Quarterly. Advisors to New Mexico Gov. Bill Richardson and Sens. Hillary Clinton (NY), Chris Dodd (CT), John Edwards (NC), and Barack Obama (IL) took part in the debate, laying out their candidates’ principles for health reform.
Clinton’s advisor, Chris Jennings–a consultant who formerly served as a senior health policy advisor to President Bill Clinton–spoke first. He said the 10 percent of patients with chronic diseases drive 75 percent of health care costs and argued high-deductible health plans don’t provide adequate coverage for preventive care and wellness.
Using Government Force
Republicans and Democrats disagree on priorities for health reform, Jennings said. While most Democrats are concerned with providing coverage for everyone, Republicans’ top priority is lowering the costs of care and increasing its quality so everyone will be able to purchase coverage if they want it.
Jennings concluded Democrats “may not have a cost-containment constituency”–meaning their backers are less concerned with lowering the cost and would accept tax hikes to pay for increased coverage.
“The Democratic candidates are based largely on the same managed competition model of requiring guaranteed issue of policies and community-rated premiums,” noted Devon Herrick, a senior policy analyst at the National Center for Policy Analysis (NCPA) in Dallas.
“The problem is, this does absolutely nothing to motivate people to be more proactive in preventing chronic illness,” said Herrick. “The only way to do that is to force people who do not follow recommended healthy behaviors or prevention guidelines to pay higher premiums. That is something none of the presidential candidates has dared to suggest.”
John R. Graham, director of health care policy studies at the Pacific Research Institute in San Francisco, agrees.
“I think that all of the Democrat health reform proposals can be summarized as, ‘Once we have “universal” health care, you will eat more vegetables and get outside more,'” Graham said. “The magic that makes this happen is left unexplained. It’s kind of like saying because the government has a monopoly on mail delivery through the U.S. Post Office, we all write our grandmothers more [often] and spell better.
“However, on the other hand, they want to remove any financial incentive for us to take care of ourselves better, the backlash against the Health Savings Accounts being a prime example,” Graham continued.
Dodd’s advisor, Barbara Smith, explained his plan in detail–“universal coverage through universal responsibility.” The plan would be modeled after the Federal Employees’ Health Benefits Program (FEHBP), with automatic enrollment and an emphasis on getting people into private insurance plans.
Smith echoed a mantra that has become prevalent in Democrat health policy circles: “Universal coverage and affordability are flipsides of the same coin … you have to have universal coverage to achieve [affordability].”
Several contenders, including Hillary Clinton, propose financing their health plans in part with savings they claim will be achieved by insuring the whole population. Market-oriented experts doubt this can work.
“When somebody promises, ‘If we do X, we will save billions of dollars,’ I would like to see just a wee bit of evidence,” said Arnold Kling, an adjunct scholar for the Cato Institute. “Is there a scalable pilot project that demonstrates these savings? Otherwise, these ‘experts’ are just blowing smoke.”
NCPA President John Goodman agrees.
“In general, preventive medicine does not save money–it costs money,” Goodman said. “There are only a handful of preventive measures that ‘pay for themselves.’ These include smoking cessation advice, prenatal care for at-risk mothers, and childhood immunizations.
“On the other hand, there is great promise in allowing the chronically ill to manage more of their own health care dollars, as is currently done in Medicaid Cash and Counseling pilot programs under way in more than half the states,” Goodman said.
Peter Harbage, a former staffer for recalled California Gov. Gray Davis (D) and a member of the team that developed Clinton’s 1993 health care plan, spoke on Edwards’ behalf, citing his general health care concerns such as focusing on getting physical education back into schools and removing junk food from them. Edwards has advocated the government creation of “medical homes” to coordinate people’s treatment.
Obama advisor Gregg Bloche, a professor at Georgetown University Law Center, discussed the importance of “healthy living.”
“We have a responsibility to take care of ourselves,” Bloche said, “by dealing with temptations like smoking and alcohol.”
Bloche characterized Republican contenders’ proposals as “promising basically nothing–more of the same.” The Republican frontrunners’ plans center on tax changes that would make health care more affordable, rather than grand new entitlement programs and broad universal coverage initiatives.
Richardson’s advisor, Sara Dash, cited a study by the Centers for Disease Control and Prevention that found “80 percent of chronic diseases could be prevented through reductions in obesity and smoking.”
The governor’s plan to achieve better health in America depends on turning “what we know into what we do,” Dash said–a catchphrase Richardson uses to refer to financial incentives and penalties, increased regulation, and more government involvement in individuals’ lives in order to force healthier lifestyles. Dash also said Richardson plans to revoke the tax-favored status of Health Savings Accounts and other consumerist health options.
Charlie Arlinghaus, president of the Josiah Bartlett Center for Public Policy in New Hampshire, says greater government intervention of this sort is entirely unnecessary.
“Addressing chronic conditions is a critical component of a pro-growth approach to controlling costs, but many businesses have figured this out without government mandates,” Arlinghaus noted.
“There are dozens of initiatives that can dovetail nicely with a focus on chronic care management,” Arlinghaus said. “Some of them, like Medicare Advantage, may be government initiatives, but many take the shape of business and insurance company initiatives to promote health among employees to lower costs.”
While both sides of the aisle agree prevention and wellness are important in improving individuals’ health, they disagree on the means needed to achieve those goals. Democrat plans would place the burden of controlling costs on government and thus would likely require individuals to undertake specific measures for prevention and wellness–a position thus far voiced out loud only by Edwards.
Republicans, by contrast, are considering ways to use incentives such as lower premiums and tax breaks to encourage healthier living.
James P. Gelfand ([email protected]) is a health policy expert in Washington, DC. Health Care News Managing Editor Karla Dial contributed to this report.
For more information …
Audio recordings of the program, as well as another forum later in the week that featured three health advisors to Republican candidates, can be found at http://www.kaisernetwork.org/health_cast/health2008hc.cfm?hc=2414.