Do Individual Mandates Matter?

Health insurance mandates are a major topic these days. Basically, to get around the politically difficult challenge of implementing truly universal healthcare, politicians and legislatures have embraced mandates as a stop-gap measure. Instead of providing care, these entities mandate individuals to obtain care for either themselves or their family members (i.e., their children) or face penalties. While in theory this should increase the rates of coverage to near-universal, it is not actually a guarantee of providing adequate care to anyone or to everyone.

My support of mandates has waxed and waned over time. It seems like they could be a good idea, but it really depends on how their implemented and enforced. If done poorly, they could actually do more harm than good. Healthcare Economist has a few thoughts on the same topic in Thoughts on individual mandates:

Health insurance require that all individuals buy health insurance. Most voters views on an individual mandate depend on how you frame the question. If you ask voters: “Should everyone buy health insurance?” Most people will say yes.

If you ask “Should the government compel all ndividuals to buy health insurance regardless of the cost?” Then the response is much less positive.

Keep reading to see what else he has to say. Interesting stuff, and an issue that potentially may affect all of us in the near future.

The McCain Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Previously, I have discussed the Obama healthcare plan and what I found interesting about it. Today, I will address John McCain's healthcare plan. The entire plan can be found here: Straight Talk on Healthcare Reform

Here are the key points that I found interesting:

• John McCain Will Reform Health Care Making It Easier For Individuals And Families To Obtain Insurance. An important part of his plan is to use competition to improve the quality of health insurance with greater variety to match people's needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.
  
  An interesting proposal, but seeing as most families receive their health insurance through their employer, I am not sure how this would be implemented. I assume he means that employers will be able to do this on behalf of their employees. Furthermore, while competition may indeed prove beneficial, health insurance differs from other goods due to the complex nature of what is covered. If policies end up competing primarily on price without regard to benefits, it is not clear how families would be better served.
  
  
  
• John McCain Will Reform The Tax Code To Offer More Choices Beyond Employer-Based Health Insurance Coverage. While still having the option of employer-based coverage, every family will receive a direct refundable tax credit - effectively cash - of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider
  
  Seems like a good idea, except from what I have heard, most plans start around $12,000 per year for a family of four, so I think the credit would have to be expanded.
  
  
  
• John McCain Proposes Making Insurance More Portable. Americans need insurance that follows them from job to job. They want insurance that is still there if they retire early and does not change if they take a few years off to raise the kids.
  
  Makes sense, but how will this be enforced? What if the company fired the employee for poor performance or illicit behavior? This gets to the heart of the problem of tying insurance to employment. Sure, employee pools make for good pseudo-random groups to insure, but it doesn't make sense in the grand scheme of things, especially when one considers that sick people generally are not good workers.
  
  
  
• John McCain Will Work With States To Establish A Guaranteed Access Plan. As President, John McCain will work with governors to develop a best practice model that states can follow - a Guaranteed Access Plan or GAP - that would reflect the best experience of the states to ensure these patients have access to health coverage. One approach would establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs. There would be reasonable limits on premiums, and assistance would be available for Americans below a certain income level.
  
  I don't understand how the government forming a "nonprofit corporation" (NPC) that covers apparently everyone that the insurance companies don't want to cover (ie, the costliest patients) is any different from a bastardized single payer system. If anything, this is worse than single payer, since this NPC would effectively take on the 'worst' patients leaving the insurance companies to cherry pick the lowest risks for themselves.
  
  
  
• CHEAPER DRUGS: Lowering Drug Prices. John McCain will look to bring greater competition to our drug markets through safe re-importation of drugs and faster introduction of generic drugs.
  
  I have the same issues here as I did with Obama's version, namely who is going to regulate this? The FDA? Also, McCain does not address the 2003 Medicare bill.
  
  
  
• TORT REFORM: Passing Medical Liability Reform. We must pass medical liability reform that eliminates lawsuits directed at doctors who follow clinical guidelines and adhere to safety protocols. Every patient should have access to legal remedies in cases of bad medical practice but that should not be an invitation to endless, frivolous lawsuits.
  
  Again, makes sense. However, without any specifics, it seems like empty rhetoric, especially under the current system, this is more a state-by-state issue, rather than a federal one.
  
  
  
• John McCain is very concerned about the rising incidence of autism among America's children and has continually supported research into its causes and treatment
  
  A nice sentiment, but is this really a national issue? Somehow, I feel like McCain has only come to care about this in the last 8 weeks or so...
  
  

Overall, I think McCain's plan has some intriguinig ideas but without more specific details, it is hard to evaluate them. Both plans seem to suffer from a lack of detail in terms of how they will pay for these proposals, implement them, or enforce them. Still, it bothers me that McCain seems to think that the solution lies in putting more power in the hands of patients without many safeguards to ensure that they actually receive adequate care. Having a $5000 tax credit isn't much solace to someone with a new diagnosis of cancer, especially if they are uninsured, since the cancer is now a 'pre-existing condition,' meaning they will not be insured in the future. Perhaps the non-profit corportation would pick up the slack here, but without much detail, who knows how that would work?

In the final judgment, I think both plans have significant deficiencies, but I believe the Obama plan to be the stronger of the two. Still, much change is needed before the U.S. healthcare system truly lives up to its potential. Your thoughts?

The Obama Healthcare Plan

As I noted in a previous post on the future of healthcare in America, both candidates have dynamic proposals for reforming our healthcare system. Today, I look at Senator Barack Obama's proposal for reform. The entire proposal can be found here: Barack Obama's Healthcare Plan (pdf).

If you click, you'll find a broad-ranging plan that is nearly 9 pages long. Here are the key points that I liked:

• Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen.
  
  I have written previously that electronic medical records need greater support in order to reap potential benefits, and this sounds like the type of commitment the healthcare community has been waiting for. A standards based approach is especially prescient.
  
  
  
• Barack Obama and Joe Biden will 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 and costs. Health plans will be required to disclose the percentage of premiums that actually goes to paying for patient care as opposed to administrative costs.
  
  Such transparency is key to forcing hospitals to improve. If the public is more aware of which hospitals are truly good and which are not, they will vote with their feet and their healthcare dollars, forcing underperforming hospitals to shape up.
  
  
  
• Barack Obama and Joe Biden believe we need to eliminate the excessive subsidies to Medicare Advantage plans and pay them the same amount it would cost to treat the same patients under regular Medicare.
  
  Makes sense, doesn't it? Why should the government pay more for what is essentially the same care provision? This is just common sense.
  
  
  
• Barack Obama and Joe Biden will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S.
  
  A good idea in theory (and a free market one, to boot). However, the plan does not provide specifics as far as which countries will be acceptalbe, and how one is going to judge which imported drugs are "safe." The FDA can barely handle monitoring domestic drugs as it is.
  
  
  
• The 2003 Medicare Prescription Drug Improvement and Modernization Act bans the government from negotiating down the prices of prescription drugs, even though the Department of Veterans Affairs’ negotiation of prescription drug prices with drug companies has garnered significant savings for taxpayers.32 Barack Obama and Joe Biden will repeal the ban on direct negotiation with drug companies and use the resulting savings, which could be as high as $30 billion,33 to further invest in improving health care coverage and quality.
  
  Thank you. Finally.
  
  
  
• Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. In fact, the most recent data available reveals that the top five percent of people with the greatest health care expenses in the U.S. account for 49 percent of the overall health care dollar. For small businesses, having a single employee with catastrophic expenditures can make insurance unaffordable to all of the workers in the firm. The Obama-Biden plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers' premiums. Offsetting some of the catastrophic costs would make health care more affordable for employers, workers and their families.
  
  Again, makes sense. This is how insurance is truly supposed to function. Instead of working to deny claims in a patient's time of need, this plan would simply cover catastrophic care. Of course, the obvious question is how much of a liability does this pose to the federal government. Furthermore, isn't this effectively nationalizing coverage anyway since the government would be the 'single payer' behind this scheme for the truly high cost cases? Hmm
  
  
  
• Obama and Biden will require insurance companies to cover pre-existing conditions so all Americans, regardless of their health status or history, can get comprehensive benefits at fair and stable premiums.
  
  A nice sentiment, and definitely something that is necessary, but without details on how this will be enforced or what the limits of "coverage" will be, it's not clear what the true impact of this is.
  
  
  
• They will also create a new 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. To be eligible for the credit, small businesses will have to offer a quality health plan to all of their employees and cover a meaningful share of the cost of employee health premiums.
  
  Sounds good, but how much will this cost? What are the cut-offs for 'small business'? Who will enforce that the businesses are actually providing good plans? Again, hmm
  

Overall, I think the Obama plan is sound and has many innovative ideas along with many items that were due for a change. However, without more details on inclusion and exclusion criteria, it is difficult to gauge how much this all will cost. Furthermore, without an enforcement scheme, it is not clear how Obama plans to ensure that all these ideas become reality in a way that protects taxpayers from fradulent claims or plain ol' waste. However, given how competently Obama has run his campaign, I can only hope that his administration would similarly find ways to effectively manage the new healthcare bureaucracies he would be creating. Your thoughts?

I'll have a post soon about the McCain plan too.

Sarah Palin: Charging Victims for Rape Kits

Gov. Sarah Palin has come under increasing media scrutiny for her political positions. However, one that is medically relevant and seems pretty indefensible is her stance as mayor on rape kits. These are the exams performed on patients who claim they are victims of rape or sexual assault. During her tenure as mayor, her town Wasilla began charging victims for these exams. Eventually, the Alaskan legislature realized how presposterous this was and banned the practice. Initially, Palin denied any involvement through a spokesperson:

Palin spokeswoman Maria Comella said in an e-mail that the governor "does not believe, nor has she ever believed, that rape victims should have to pay for an evidence-gathering test."

"Gov. Palin's position could not be more clear," she said. "To suggest otherwise is a deliberate misrepresentation of her commitment to supporting victims and bringing violent criminals to justice."

Comella would not answer other questions, including when Palin learned of Wasilla's policy or whether she tried to change it. The campaign cited the governor's record on domestic violence, including increasing funding for shelters.

However, further investigation found that Palin indeed did sign into law the budget cuts that forced victims to be charged for the rape kits:

Under Sarah Palin's administration, Wasilla cut funds that had previously paid for the medical exams and began charging victims or their health insurers the $500 to $1200 fees. Although Palin spokeswoman Maria Comella wrote USA Today earlier this week that the GOP vice presidential nominee "does not believe, nor has she ever believed, that rape victims should have to pay for an evidence-gathering test...To suggest otherwise is a deliberate misrepresentation of her commitment to supporting victims and bringing violent criminals to justice," Palin, as mayor, fired police chief Irl Stambaugh and replaced him with Charlie Fannon, who with Palin's knowledge, slashed the budget for the exams and began charging the city's victims of sexual assault. The city budget documents demonstrate Palin read and signed off on the new budget. A year later, alarmed Alaska lawmakers passed legislation outlawing the practice.

For someone who is clearly running on the premise that as a mother of 5, she will champion women's rights if elected to higher office, this is a sad and shocking situation. Putting aside her views on abortion, this in itself should be a signal to people whose primary issue is women's rights whether Palin truly represents their interests. And, as health professionals, I would hope that this situation is not repeated in other locales, although it undoubtedly has been in the past.

Sarah Palin's Birthing Guide

As I am on Ob/Gyn right now, a friend sent this to me regarding the controversy surrounding Sarah Palin:

Pregnant? Out of state? Practice the Palin Method!

Just as the pundits predicted, America is falling in love with Sarah Palin, America's supermom -- and soon to be grandmom (and maybe even great-grandmom, depending on whether Bristol has a girl and how soon that girl becomes fertile). Palin, as we're finding out, is a "maverick," who "does things her own way." Including not only the way she runs a family, but the way she creates a family. Lost in the rumor about whether Palin had faked her last pregnancy was the true story of how Palin actually had her last child Tram Trim Trig.

While some choose natural childbirth, some choose Lamaze, and others choose traditional hospital arrangements, Palin chose to get on a plane after her water broke and fly from Texas to Alaska, with a stop in Seattle. Was it because she wanted to be closer to God? Or did she hear about Alaska Airlines Northern Bites® Hearty Picnic Pack ($5)? Nobody knows, but, hey, the baby's alive, so the gamble paid off. Plus, you don't get frequent flyer miles in Lamaze class, ladies.

Palin, as the country is about to learn, has lots of ideas about how you should run your life. Including the part that involves your vagina (lots of ideas about that area).

So if you're pregnant, and bored with the tired old risk-free method, try the Palin method...

Keep reading to see the Sarah Palin 9 Step Method to giving birth.

The Future of America's Healthcare: Obama vs. McCain

Recently at dinner, a few friends and I were discussing politics and healthcare. While we all had our own opinions, we came to the sad realization that none of us really knew the candidates plans in depth. I had previously written about Obama's and Clinton's healthcare plans, but that was months ago, and did not include anything about McCain's proposals. Curious, I tried reading a little bit online about the two proposals. I came across an article in the New England Journal of Medicine regarding their positions:

McCain's plan embraces market forces and promotes individually purchased insurance (see red box). Its centerpiece is a change in the tax treatment of health insurance. Currently, workers do not pay taxes on health insurance premiums paid by their employers. The McCain plan would eliminate this tax exclusion and use the revenue generated — projected to be $3.6 trillion over 10 years — to pay for refundable tax credits for Americans obtaining private insurance ($2,500 for individuals, $5,000 for families). Uninsured Americans could use their credits to help buy insurance coverage on the individual market, and workers with employer-sponsored insurance could use theirs to offset the cost of paying taxes on their employers' premium contributions or to purchase coverage on their own.

^{The article discusses Obama's healthcare plan well:}

In contrast to John McCain's emphasis on markets and deregulation, Barack Obama's reform plan relies on an employer mandate, new public and private insurance programs, and insurance-market regulation (see blue box). The core of the Obama plan is a requirement that employers either offer their workers insurance or pay a tax to help finance coverage for the uninsured (some small businesses would be exempt, and others would be subsidized). The Obama plan would also create two new options for obtaining health insurance: a new government health plan (similar to Medicare) and a national health insurance exchange (a purchasing pool analogous to the Massachusetts Connector) that would offer a choice of private insurance options. Both would be open to persons without access to group health insurance or other public insurance, as well as to small businesses that wanted to purchase coverage for their workers. Income-related subsidies would be provided to help lower-income persons afford coverage. And private insurers could not deny coverage because of preexisting conditions or charge substantially higher premiums to sick enrollees: the Obama plan would end medical underwriting according to health status.

^{Admittedly, I am a bit biased towards Obama, but I think I'll discuss my thoughts in a future post after I have had more time to digest their proposals. Anyone out there already come to a conclusion? How does McCain's free market solution compare to Obama's hybrid government / competition plan?}

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Medicine, Teen Pregnancy, and Bristol Palin

The big story this week, after news broke that John McCain had selected Alaska governor Sarah Palin as his running mate (and soulmate, apparently), was that her daughter 17 year old Bristol Palin is 5 months pregnant. As I am currently on my Ob/Gyn rotation, I wondered what additional risks being pregnant as a teenager carries. 

Per the American Academy of Child and Adolescent Psychiatry, teenage pregnancies carry many risks for the teen mother and her child:

Adolescents who become pregnant may not seek proper medical care during their pregnancy, leading to an increased risk for medical complications. Pregnant teenagers require special understanding, medical care, and education--particularly about nutrition, infections, substance abuse, and complications of pregnancy. They also need to learn that using tobacco, alcohol, and other drugs, can damage the developing fetus. All pregnant teenagers should have medical care beginning early in their pregnancy.

Teen pregnancies themselves have been declining in recent years, but have started to rise again:

Teen pregnancy rates in the United States declined steadily from 1991 to 2005—from 60 out of 1000 teenagers in 1991 to 40.5 out of 1000 in 2005. In 2006, however, the teen pregnancy rate increased to about 42 out of 1000. Approximately one-third of young women in the United States become pregnant during their teens. More than 80% of teen pregnancies are unintended and unintentional. The highest teen birth rate occurs in Hispanic women (83 out of 1000 in 2006).

Apparently, the Aleutian women are holding their own. Heh, anyway interestingly, this decline is attributed to sex education, which McCain and Palin oppose: 

Declining teen pregnancy rates are thought to be attributed to more effective birth control practice and decreased sexual activity among teens. The most dramatic reduction in teen pregnancy—23%—has occurred among African American teenagers.

Going back to the baby, it faces risks beyond merely those to its health:

In addition to increased health risks, children born to teenage mothers are more likely to experience social, emotional, and other problems. These problems include the following:

• Children born to teenage mothers are less likely to receive proper nutrition, health care, and cognitive and social stimulation. As a result, they are at risk for lower academic achievement.
• Children born to teenage mothers are at increased risk for abuse and neglect.
• Boys born to teenage mothers are 13% more likely to be incarcerated later in life.
• Girls born to teenage mothers are 22% more likely to become teenage mothers themselves

Overall, a sad situation, one that would strain any family. Hopefully, some will benefit from the increased awareness of the problems of teen pregnancy due to this situation. 

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Stephanie Tubbs Jones, 1949 - 2008

Stephanie Tubbs Jones died last week of a brain hemorrhage after a cerebral aneurysm ruptured. Per reports, she was found unconscious in her car and rushed to an Ohio hospital with limited brain function. She died the next day. Her story sparked some controversy as she was initially reported to have died while she was in fact still alive but in critical condition. On a tangentially related note, recently named Vice Presidential candidate Joseph Biden has also suffered from cerebral aneurysms. He was absent from the senate for roughly 7 months in 1988 to correct 2 aneurysms.

Why mention this sad news here? Well, I don't know much about aneurysms but I wonder if we will ever able to develop a cost-effective, benign way to screen for them. Right now, I believe the options are basically a CT head with contrast or a cerebral angiogram, but the former exposes the patient to radiation while the latter not only has the radiation exposure but is also invasive. Still, given the catastrophic outcomes of a ruptured aneurysm, I wonder what the cost-benefit analysis of screening would be. Anyone out there have any idea? Just curious.

Three's Company, Four's A Treatment Plan?

Having discussed second opinions before, it was interesting to read about how Sen. Ted Kennedy, who was recently diagnosed with a brain tumor, sought the advice of experts:

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

If only the rest of us could summon dozens of experts to our bedside to discuss our ailments. However, the article does go on to note that many experts do look at the records of regular patients with unique cases. Still, the piece does say that:

Just sending images and records is far less preferable than meeting with a patient before rendering an opinion. “I do not operate on films,” Dr. Flamm said. “I operate on people.”

Meeting with patients “is an important factor in terms of their expectations and concerns,” he continued, adding: “I can see a white ball on a scan and say yes, that is a tumor, I agree. Beyond that it is rather difficult to come up with a treatment plan based on that, other than saying, yes I would operate or I won’t.”

Hm, it seems that privilege indeed still does have its benefits in America.

Medicare Update

Last week, I posted about the proposed 10.6% cut in Medicare payments and its impact on the healthcare system. Since then, President Bush vetoed a bill that would reverse this scheduled change, but Congress overruled his veto:

But the House voted, 383 to 41, on Tuesday afternoon to override the veto. Soon afterward, the Senate voted by 70 to 26 to do so. Although the Senate vote was close enough to provide some suspense, it was still over the two-thirds needed, as a number of conservative Republicans who typically side with the president broke with him on this issue.

The bill cancels a 10-percent cut in payments to doctors that would otherwise occur automatically because of a statutory formula that reduces payments when spending exceeds certain goals. The president said he supported the main objective of the bill, to forestall reduction in physicians’ payments, but that he had too many reservations about other aspects of the legislation.

Mr. Bush said he opposed the bill in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield. In his veto message to Congress, Mr. Bush also complained that the bill would “perpetuate wasteful overpayments to medical equipment suppliers.”

It will be interesting to see how this plays out the next time there is a scheduled change in Medicare payments. The current system seems untenable in the long run, but with all the vested interests, it seems like it will be hard to change the status quo anytime soon.

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Hillary Clinton Is Out Of Touch With Radiologists

During a recent campaign swing through Indiana, Hillary Clinton had this to say about radiology (yes, radiology):

Next she shared the alarming news that American radiologists are losing jobs because X-rays are being sent electronically to India. But the outsourcing of radiology is not precisely what Mrs. Clinton made it out to be; according to Frank Levy, a professor at the Massachusetts Institute of Technology, there is only one company in India that reads American images. The overseas radiologists who read American images are generally American citizens themselves, said Mr. Levy, because doctors who have not passed American boards cannot be insured against malpractice.

Oh, Hillary. Stick to the politics, okay? And fine, while this is a threat in the future I suppose, she should be more careful before making such claims since it's easily falsifiable.

Projection: The Politicians' Defense Mechanism

Projection is a type of psychological defense mechanism. According to Wikipedia, it is defined as:

In psychology, psychological projection (or projection bias) is a defense mechanism in which one attributes one’s own unacceptable or unwanted thoughts or/and emotions to others. Projection reduces anxiety by allowing the expression of the unwanted subconscious impulses/desires without letting the ego recognize them.

For some reason, this seems to be a fairly popular defense mechanism among celebrities, especially politicians. Here are a few notable examples:

Eliot Spitzer

The former New York Governor recently resigned after he was found to have frequented prostitutes. Why projection? Prior to being elected governor, Spitzer had served as New York's Attorney General, and was particularly aggressive in enforcing the law. Seems like he was projecting his own moral failings on others.

Larry Craig

The former Senator from Idaho resigned after he was caught in an investigation about male prostitution in the Minneapolis Airport. Why projection? Prior to this discovery, Craig was outspoken in his opposition to same-sex marriage.

Gary Hart

The former Presidential candidate and Senator was found to be having an affair after claiming not to be involved in one and challenging reporters to follow him around. I suppose this isn't really projection, but the hubris of such a challenge is something to behold.

History is filled with many more such examples, such as Henry Hyde leading the impeachment hearings against President Clinton, even though he had engaged in an affair years before himself, or noted segregationist Strom Thurmond having fathered a child with an African-American woman. I suppose there are many more politicians who have no such failings, but it almost seems like projection is part of the job description.

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Democratic Candidate Healthcare Proposals

I was recently discussing politics with a friend who is interested in health policy (and is also a med student). I realized that while I knew the general ideas that the candidates had, I wasn't too familiar with the specifics. I had tried previously to go to candidate websites, but I found myself getting bogged down, as each one had a different way of presenting their proposals. I asked my friend if there were any sites that simply compared the different policies. He directed me to health08.org, a website run the Kaiser Family Foundation. The site was easy to use, and let me compare any candidate's plan against any other candidate's plan.

As I tend to be liberal-leaning, I compared Senator Clinton's plan with Senator Obama's and Senator Edwards'. The comparison was fairly helpful, as it went through the plans and compared them on a point-by-point basis. Here's a summary of each plan, and my opinion of them:

Clinton: Every American is required to have coverage. To make this affordable, the plan will provide income-related tax subsidies. Plan options, both public and private, will be available through a "Health Choices Menu," which would be operated by the Federal Employee Health Benefits Program. Coverage through employers and public programs would continue. Employers of small businesses would receive a tax subsidy to offset their costs. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $250,000.

Obama: Every child will be required to have coverage. Employers will either have to extend benefits or contribute to a new public plan. A new "National Health Insurance Exchange" would facilitate enrollment in the new public plan. Employers would receive tax benefits to offset catastrophic costs. Cost estimate: ~$60 billion, partly financed by rolling back tax cuts on those making over $250,000.

Edwards: Every American is required to have coverage, with a goal of universal coverage by 2012. The plan would create nonprofit "Health Markets" in which public and private options would compete with each other. Expanded public funding for coverage of low income adults would also be provided for. There is no provision for employers. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $200,000.

The three candidates are providing the same healthcare plan with minor tweaks. I think Obama's would benefit from mandating coverage, but on the other hand, the plans with mandates do not technically guarantee coverage. Simply by saying you must be covered doesn't necessarily make it so. And what are we going to do if people choose not to buy? Fine them? Put them in jail? Maybe I am not understanding the mandate, but if they really want universal coverage, they should just expand the Medicare payroll tax deduction and call it the "National Healthcare" payroll deduction. Of course, that will never happen, but I'm jus' sayin'... Anyway, given what I've read, I think Clinton's and Edwards' plans sounds the best and have more detail. Obama's is good, but not as broad as theirs; however, his plan might be the one that is most realistically implementable. It is interesting to see his views on policy. I think Obama would be in support of mandates if crafting a system from scratch, but in this climate, perhaps he believes that a more incremental change is more feasible. I suppose I should admit a bias towards Obama, but I think any one of the candidates I mentioned above would be more than competent.

To be fair, here is what I understand of some of the other candidates' plans (in no particular order):

Giuliani: Healthcare reform 9/11. Now.

Paul: Ban healthcare as it was not mentioned in the Constitution.

Huckabee: Plan members will ask themselves, "What would Jesus do to heal himself?" instead of making claims.

Kucinich: Mars has healthcare for all, so why can't we? I was the first to propose the Martian plan.

Thompson: Healthcare reform in U.S. America... [yawns]... is something.... umm, line?

=) Anyway, hopefully whoever is elected president in 2008 will bring about meaningful change to our system, which is clearly in need of reform.

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