Wonking us to sleep

As I have said before, I'm not going to be all over the health care proposals of the presidential candidates because whatever they are saying now is not miraculously going to become reality after January 20. It's all going to get processed through the Congressional/K Street/Moronic Corporate Media meat grinder anyway, and who knows what vile offal might emerge?

But, the debate last night has no doubt raised questions in people's minds regarding what that was all about with the mandates and the amputations and what not. Let me say, first of all, that the debate as a whole was extremely heartening. It was largely substantive, we've got two capable candidates who both demonstrated a willingness to submerge their competing personal ambitions for the good of the nation, and it would be absolutely shocking if one of them doesn't become president. Whoever it is will spend the next few years shoveling out a shitpile that makes the Augean stables seem like your cat took a dump on the rug, but maybe they'll get something done on health care.

So, you can go to the respective web sites and read it all for yourselves, but here's my executive summary.

Both posted plans are largely qualitative. They are short on numbers and dollars, which makes it very hard, nay impossible, to judge how things would really work out. I suppose that's inevitable. If they put the numbers up there people would start crunching them and yelling about a $100 billion tax increase and what not. But, for what it's worth --

They both start by letting anyone who wants to buy into the health insurance program for federal employees, called the FEHB. One very important issue that they're both a little bit vague about is what's called "rating." They are clear that nobody can be denied this coverage due to pre-existing conditions, but it is not 100% clear that everybody will pay the same price regardless of age or health status. This is important because of the way health insurance markets work. Both Clinton and Obama propose tighter regulation over private insurance, but Obama is explicit that private insurers could adjust premium levels based on risk, although he doesn't say how much. The problem, if we stop short of requiring national community rating (i.e., everybody pays the same price), is that the FEHB would end up soaking up all the higher risk people and families that private insurers don't want, leaving them to "cream" the lower-cost beneficiaries. This potentially makes the national insurance program unsustainable.

They both say there will be subsidies for low and moderate income families that aren't eligible for Medicaid, to buy into private insurance or the national plan, but they don't quantify these. They'll limit the cost to some percentage of income, but they don't say how much. They will tax employers who don't offer coverage, but again they don't say how much.

The big difference that they argued about last night is the mandate. Clinton would require everyone to have insurance, as in Massachusetts. Obama is afraid that this will force some people to buy insurance they can't afford, but that would seem to undermine his other claims about his plan. Assuming the subsidies and premium caps are adequate, the issue about the mandate is not affordability at all. Its those healthy young people in their 20s who would rather spend the money on an X-Box and a steak dinner at Smith and Wollensky's because they figure they don't need insurance. Getting them into the pool is important because it helps to subsidize the expensive older folks with diabetes, to put it crudely.

Both of them talk about investments to make the system more efficient, suchas electronic medical records -- which may or may not turn out all they're cracked up to be -- but Obama has a great deal more to say about this. Again, it's qualitative and often a bit vague. He wants to require insurers to cover disease management programs, which is definitely a good idea. Right now, they won't pay for intensive supports for people with, say, diabetes, to help them manage their condition and avoid complications down the road. The reason, although Obama doesn't say so, is that by the time you need your amputations or your kidney dialysis, you probably won't be on their plan any more -- either because you turned 65 and went onto Medicare, or you lost your job -- so why should they pay now to avoid those costs later on? (That's where his remark last night about amputations comes from, BTW.) Society would save in the long run if they did, but they don't care about that, they aren't in business for their health.

Obama also wants to establish an equivalent of the British National Institute for Clinical and Health Excellence, to recommend evidence based practices and discourage wasteful interventions. Good idea, especially if the recommendations are somehow enforceable. He also talks a lot about public health but without mentioning any dollar amounts.

Bottom line, though? This kind of piecemeal, half-assed reform doesn't work in the long run, because it doesn't get everybody into a single pool and doesn't ultimately get a cap on costs. We need universal, comprehensive, single payer national health care. But maybe these baby steps will have the virtue of making that obvious.