Posts Tagged ‘hillary clinton’

Med Mal: Sometimes The Best Defense Is … No Defense

May 19, 2008

A lot of attention is being given to yesterday’s New York Times piece about doctors and hospitals who apologize, ‘fess up, and correct their mistakes when they make medical errors. For medical professionals who have been trained to “deny and defend,” the whole idea seems counterintuitive. It’s a natural instinct for people to want to hide their mistakes. And as Michael O’Hare points out, it’s also something attorneys have been telling their medical malpractice clients to do for a long time.

I’ve written about the Sorry Works! Coalition before, and they’re mentioned in the Times article. That’s the group that’s dedicated to becoming “the nation’s leading advocacy organization for disclosure, apology (when appropriate), and upfront compensation (when necessary) after adverse medical events.” The Times suggests that there is now a data trail for the medical disclosure movement. Reporter Kevin Sack writes:

Despite some projections that disclosure would prompt a flood of lawsuits, hospitals are reporting decreases in their caseloads and savings in legal costs. Malpractice premiums have declined in some instances, though market forces may be partly responsible.

O’Hare tells an anecdote about working with a hospital whose in-house counsel promoted a similar policy 25 years, with very positive results. That sounds right: During my years inside the insurance industry I saw similar examples of the seemingly counterintuitive. Sometimes ‘fessing up is the best defense.

And there’s a political movement to institutionalize medical disclosure. Sack quotes the director of Sorry Works! as saying that “34 states have enacted laws making apologies for medical errors inadmissible in courteven require that patients be notified of serious unanticipated outcomes.” He observes that Democratic Presidential candidates Clinton and Obama cosponsored a similar resolution in the U.S. Senate, only to see it die in a GOP-controlled committee.

This should be an ideal topic for bipartisan support, given the Republican penchant for criticizing excessive med mal settlements. So why would Republicans kill a bill like this one? I don’t get it.


“Universal Coverage” – Only Words

April 21, 2008

It’s only words, but words are all I have to steal your heart away …1

My wife and I stood at the curb saying goodbye to our friend Maureen last week. The election came up, and Maureen said “I like the candidate that’s going to provide universal coverage.” Here’s the problem: there’s no such candidate this year. Maureen’s been had.

But first, a question: What’s wrong with this sentence, from my friend Joe Paduda’s informative write-up of the World Health Care Congress, referring to the difference between the Clinton and Obama health plans?

“… [Clinton] wants mandated universal coverage and [Obama] does not.”

The italics were a hint: Joe and I agree, as does our mutual friend Bob Laszewski, that the two plans are essentially similar. But their primary difference, which is that the Clinton plan includes mandates for adults, can not accurately be described as “universal coverage.” The Massachusetts experience has demonstrated that conclusively.

Even if a mandate plan were to be passed, millions of today’s uninsured would – by my estimation – remain uninsured. Millions more would benefit, as they would under a non-mandated plan, but we’d have nothing like genuine “universal coverage.” And many working Americans would face new financial pressures, without receiving better health coverage in return.  (My numbers and logic are laid out in a footnote.)

I expressed early and serious concerns about the Massachusetts plan, and there’s no pleasure in reporting that they have proved justified. The plan’s been very effective in providing coverage for those who qualify for full subsidies. But it has been far less effective for lower-income working people. Subsidies don’t reach them, and the difference between plan premiums and the mandated tax penalties they face is still a big-dollar amount for their budgets.

The result? These hard-pressed Americans still don’t have health coverage … and they’ve been hit with more taxes.

The Massachusetts plan is a lot like Clinton’s, in a state with a much less complex uninsured problem that other parts of the country – and it’s been forced to exempt 20% of the uninsured. That’s not “universal coverage,” it’s health mandates – and while it will provide coverage for some, many will fall through the cracks.

Why does this matter? Why am I harping on the choice of words? Because perception drives reality in politics. Maureen thinks her candidate will provide “universal coverage” if elected. Here’s what will really happen if Maureen’s favorite gets the nomination – she’ll be hammered by her opponent in the general election over the enormous added tax burden to lower-income working families. If she wins, her plan will face far greater political opposition because of the mandate provision – which will most likely be dropped as a result. If, against all odds, these obstacles are overcome and a mandate provision is passed,

Based on rough calculations, I agree that Obama’s plan would leave approximately 15 million uninsured. But I estimate that Clinton’s plan would leave 8 million uninsured – and is far less likely to pass in Congress.2 (Each plan has its own strengths in the cost-cutting and health oversight areas – and McCain’s isn’t really a “plan.” It’s more of a “wealth-transfer-device” for the already well-to-do … but that’s another topic.)

What about the argument that a mandate plan can’t pass?

Not so, says Paduda. He quotes Obama surrogate Rep. Jim Cooper as saying the mandate provision – which Joe again mischaracterizes as “universal coverage” – will get “zero Republican votes,” which he calls “a completely wrong statement.” Joe cites the mandate-driven Wyden Health Plan, with six Republican co-sponsors, as proof.

But the Wyden plan, which takes employers out of the health insurance game, has a couple of carrots to offset the “mandate” stick. One’s for working people: It requires employers who currently provide coverage to boost salaries to offset for the huge expense savings they’ll get. That puts money back in people’s pockets. The second is for employers: Salaries are rising at a much slower rate than health premiums, and they have more control over them, so this is a financial win – especially for larger corporations.3

I’ve talked to many employers over the years – large and small – who would love to get out of the health benefits business. And I’d argue that the Wyden bill can be pitched as more attractive to lower-income working people. I suspect these differences make the Wyden bill GOP-friendly enough to offset for its universal coverage mandate provisions. (That said, it’s excessive of Rep. Cooper to suggest that a mandate bill would get “zero” Republican votes. There might be handful, but probably not enough to pass …)

So we watched Maureen pull away from the curb, content in her belief that at least one Presidential candidate would bring the country “universal coverage.” Can’t blame her: a lot of smart people think so, too.

Too bad life ain’t so simple …


1What would a wonkish health policy post be without quoting at least one Bee Gees song? Others I could have cited here include “Stayin’ Alive” – and, of course, “Massachusetts.”

2Quick and dirty calculation: Massachusetts, which is demographically less challenging than other parts of the country (fewer illegal immigrants, etc.), was forced to exempt 20 percent of the uninsured from its plan. Planners in more variegated California expected that 30% would have to be exempted. So, even the generous assumption that mandates will do as well nationally as they have in Massachusetts gives us a 20% exemption rate. If we assume 40 million uninsured nationwide, then 20% = 8 million. That ain’t universal. Thus, the difference between an Obama plan that excludes 15 million and a Clinton plan that excludes 8 million is 7 million.

What’s left to consider? First, whether you think a mandate plan can pass Congress. If it can’t, everybody loses. Second, your personal opinion of whether mandates for hard-pressed working families are a) a way to force them to pay their fair share, or b) another regressive tax that places too much burden on those at the lower end of the spectrum.

3Re the Wyden plan, I like the concept. Unfortunately, though, I can see a number of ways that employers could game it. But that’s for another day.

Heated Debate Over Mandates

February 7, 2008

The intensity of debate around health care reform is reaching new heights, especially around mandates. They were a key part of the Massachusetts reform law and are central to the Clinton health proposal. Obama’s reform plan does not include a mandate provision, at least initially, although he indicated during the early debates that he would consider adding one later if voluntary programs don’t succeed in getting near-universal coverage.

Clinton has been hammering Obama over this issue for months, saying that her plan guarantees “universal coverage” and his doesn’t. Here’s the simple fact: Mandates do not create universal coverage. When the pundits were celebrating the “Massachusetts miracle” — including many of the same “health wonks” now touting the Clinton plan — I was one of the few to point out that the plan was actually more mirage than miracle. It kicked the unpleasant decisions down the road so that Mitt Romney and his Democratic and labor collaborators could take an undeserved victory lap at the signing ceremony.

Sure enough, the legal authority responsible for the Massachusetts plan eventually acknowledged that the plan will leave 20% of that state’s uninsured without coverage, and the real number may be higher. Why? Because there is a wide band of people who would suffer financial hardship if compelled to pay the premiums, and it’s financially infeasible to subsidize them all.

The Clinton plan, should it ever be passed, will suffer the same fate. I will happily bet Paul Krugman on that point. He should know better than to claim that the Clinton plan could provide universal coverage. Experience and political common sense say that just ain’t so.

That’s not to say there aren’t valid arguments in favor of mandates. There are, which is why they’re part of conventional health policy wisdom. Mandates solve the “selection problem,” where insurance costs become too high because only sicker people buy insurance voluntarily. They also allow funds that are now used to reimburse providers for treating the uninsured to be used in better ways. And I think the Obama team is over-optimistic about voluntary compliance levels.

Krugman and other supporters of the Clinton plan are now pointing to a study by the respected Urban Institute as a validation of their position. It’s a good study that shows mandates are the only way to achieve something like “universal coverage” — if you first exclude single-payer coverage from the mix. (They also exclude my preferred approach — core basic coverage paid from tax revenues, with the ability to “buy up” into private plans through a subsidy/voucher approach.)

Here’s one problem: The paper’s authors admit, albeit indirectly, that they overestimated the ability of Massachusetts to achieve universal coverage. They make the same mistake here. Here’s another: Sen. Clinton and the supporters of her plan have been evasive about how they would enforce this mandate, and enforcement is key to the Urban Institute’s findings. In a recent interview she was forced to acknowledge, for example, that she would consider garnishing wages. And while she has boasted about tying mandate obligations to personal income, she has been equally vague about what level of personal income she might allocate for healthcare.

Those provisions are political non-starters. Massachusetts is easy compared to the country as a whole — both in terms of political climate and the scope of the uninsured problem. Yet they had to leave 20% of the uninsured without coverage. That figure would equate to about 8 million people nationwide. If we accept Sen. Clinton’s figure of “15 million uninsured” under the Obama plan (and that figure was chosen by a journalist, not a technical study), that means a difference of seven million — in return for a plan that might actually get passed in Congress. (The gap could be filled in later, after premiums are brought under control and it becomes more politically feasible.)

And consider what mandates might do to a family of four. While Clinton won’t tell us the percentage of income she’d tie to mandates, many analysts have been using 10%. If premium assistance is provided up to 300% of the poverty level, a family of four trying to survive on $75,000 could be forced to pay $7,500 to insurance companies or in health copayments. The alternative could be tax penalties or garnished wages. That seems unfair. I also believe it’s a serious misread of American political culture to think that kind of mandate could ever get through Congress.

Krugman was outraged by an Obama ad that seemed to channel “Harry and Louise” from the 1994 anti-reform campaign. He says that mandates are to “prevent some people from gaming the system,” he writes, as if that family of four could write out that $7,500 check if not for some moral hazard. (Granted, there are “gamers,” but they tend to be the young, healthy, and relatively prosperous.)

We already have a mechanism for “shared responsibility,” and it’s called taxation. Adding 10% to struggling families’ financial burdens reads politically like a highly regressive tax to be paid to insurance companies – and the Wall Street Journal suggests that insurance companies do prefer the Clinton plan. That could create rough political waters in the general elections, especially for a Democrat.

While mandates have real value, political realities and issues of fairness suggests that the health reform process should start elsewhere. What’s even more clear is that they are not a mechanism for creating “universal coverage,” whatever the politicians say.

(extracted from a piece in the Huffington Post)

Health Mandates: A Talk With Obama Health Advisor David Cutler

December 1, 2007

Hillary Clinton, John Edwards, and Barack Obama have each presented detailed proposals for health reform. The Clinton and Edwards plans include health mandates, which require Americans to obtain health care coverage or face (unspecified) sanctions. The Obama plan does not include mandates.

Health mandates are popular among many Democratic-leaning health policy analysts. The Clinton campaign has been going after Obama aggressively on this issue. They’ve said that the absence of mandates is a basic flaw in Obama’s plan; suggested a cynical political calculus behind Obama’s position said that his position feeds a Republican narrative; and took the position that Obama’s plan is politically vulnerable while theirs (and Edwards’) is a political plus in the general election.

(The preceding positions were echoed today by Paul Krugman – see my response, “Why Paul Krugman Is Wrong …“)

I don’t support any Democratic candidate, but I do have strong opinions about health mandates. As a long-time healthcare policy analyst and health manager in the private sector, I disagree with Paul Krugman, Ezra Klein, Jacob Hacker, and others who support mandates. My differences are based on policy effectiveness, issues of fairness, and Democratic political strategy. I think mandates pose more problems than they solve, and that they could be a political loser for Democrats in the general election.

I’ve been engaged in a collegial debate with Klein, blogger/consultant Joe Paduda and others on this topic for some time (see, for example, here, here, here, and here). During an exchange with Klein over the last week it became apparent that, while I had reasons to support Obama’s policy, it was unclear to me what his team’s current thinking was on the topic.

The team published a rebuttal to Clinton’s campaign late today. Earlier I spoke with David Cutler about mandates. Cutler is Professor of Applied Economics at Harvard, Obama’s senior health advisor, and the principal architect of the Obama plan.

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Why Paul Krugman Is Wrong About Health Mandates

December 1, 2007

Now there’s an intimidating headline to write. Paul Krugman slammed Barack Obama today on the issue of health mandates. Here’s why I believe he’s wrong:

From the beginning, advocates of universal health care were troubled by the incompleteness of Barack Obama’s plan, which unlike those of his Democratic rivals wouldn’t cover everyone.

Two misstatements in this opening sentence. First, while it’s true that Obama’s plan won’t “cover everyone,” neither will anyone else’s. Mandates have never achieved 100% effectiveness. The practical design problems of subsidies, exemptions, and benefit levels that accompany mandates are complex and unwieldy.  That’s why the Massachusetts Authority responsible for that state’s plan – which Krugman would describe as “covering everyone” – just exempted an estimated 20% of uninsured residents from the mandate.

Secondly, the absence of mandates is not necessarily an incompleteness in the Obama plan. I’ll be posting my conversation on this topic with Obama health advisor David Cutler shortly.

Here’s why: under the Obama plan, as it now stands, healthy people could choose not to buy insurance — then sign up for it if they developed health problems later. Insurance companies couldn’t turn them away, because Mr. Obama’s plan, like those of his rivals, requires that insurers offer the same policy to everyone.

As a result, people who did the right thing and bought insurance when they were healthy would end up subsidizing those who didn’t sign up for insurance until or unless they needed medical care.

Mr. Krugman raises some valid concerns here. But what he doesn’t say is that this would only be a temporary problem under the Obama plan. If it failed to achieve enrollment rates high enough to offset this ‘selection effort,’ other measures would be used – including potentially mandates.

The main difference between Obama’s plan and his rivals’ is this: They would mandate health coverage first and fix cost problems later. Obama would do the opposite. While both approaches are problematic, there is a strong case to be made that Obama’s plan is fairer – and much more politically progressive.

Mr. Obama claims that mandates won’t work, pointing out that many people don’t have car insurance despite state requirements that all drivers be insured. Um, is he saying that states shouldn’t require that drivers have insurance? If not, what’s his point?

His point is that the Clinton and Edwards claim – that they provide “universal coverage” – is false. If mandates don’t result in “universal coverage” – and the Massachusetts experience seems to confirm that – than this statement is hyperbole, not fact, and the debate is really about how many people to cover and how fast .  It’s not the black-and-white issue the campaigns are making it out to be.

Mr. Obama accuses his rivals of not explaining how they would enforce mandates, and suggests that the mandate would require some kind of nasty, punitive enforcement: “Their essential argument,” he says, “is the only way to get everybody covered is if the government forces you to buy health insurance. If you don’t buy it, then you’ll be penalized in some way.”

Well, John Edwards has just called Mr. Obama’s bluff, by proposing that individuals be required to show proof of insurance when filing income taxes or receiving health care. If they don’t have insurance, they won’t be penalized — they’ll be automatically enrolled in an insurance plan.

That’s a “terrific idea” with no penalties, Mr. Krugman says. Okay, let’s amend Obama’s choice of words slightly: when people are enrolled in a plan automatically and then don’t pay the premiums they’ll be “penalized in some way.” That’s not hair-splitting – it’s a huge difference. If a family of four is enrolled in a health plan with $10,000 annual premiums, that’s a burden. What will happen if they don’t pay?

We’ll fix that with subsidies, says the mandate crowd. But how much will people actually pay? They’re not saying.

I recently castigated Mr. Obama for adopting right-wing talking points about a Social Security “crisis.” Now he’s echoing right-wing talking points on health care.

I agree with Mr. Krugman about the Social Security issue. And I understand the concern about the use of words like “forced” by the Obama campaign. I understand the concern about the use of words like “forced” by the Obama campaign.  But that’s mild compared to the words the GOP will use in 2008 – and they’ll say them no matter what Obama does or doesn’t do. So rather than crying “foul” when someone challenges them, the Clinton campaign and others should use this as an opportunity to sharpen their talking points – or primary voters may conclude they don’t have it in them to make their case when the going gets tough.

More on Mandates: Ezra’s Take

November 27, 2007

Is Obama’s decision not to include mandates for health coverage “a policy … his campaign regards as a mistake”? Ezra Klein believes so. Maybe he has some insider info that’s not available to the rest of us. But even if the Obama campaign thinks it’s a mistake, I don’t.

Ezra’s piece is an emphatic and succinct summary of the pro-mandate arguments being made from the left by a number of progressive Democratic health policy analysts. Ezra writes:

I’m getting really tired of Obama’s constant excuse that his health care plan isn’t universal because “The reason Americans don’t have health insurance isn’t because they don’t want it, it’s because they can’t afford it.” The reason Americans don’t all have flat screen televisions is because they can’t afford those, too.

That’s true, I suppose – although I’d hesitate to use an analogy between healthcare and expensive consumer electronics when critiquing a policy from the left. But we’re not mandating televisions. And the mandate we are discussing won’t achieve its stated goal of “universal coverage.”

Most experts agree that compliance with a health mandate will be notably less than universal. It will be greater under the Clinton plan than it would be under Obama’s mandate-free alternative. But we’re talking about relative degrees of coverage, not the “universality” that will remain somewhat elusive even under mandates.

We share similar concerns about each of the Democratic candidates, but Ezra specifically sees Obama’s no-mandate position as a betrayal of progressive principles. He writes of his hopes, now unrealized, that Obama would argue “we as a society needed to unify, come together, make temporary sacrifices to build a better world.” Ezra adds, “his remarkable eloquence rendered him uniquely able to articulate the larger progressive narrative, that our nation must move forward as ‘we,’ rather than continue as a country of I’s.”

Here’s my response: First, when it comes to universal coverage and mandates it’s not a black-and-white matter of “we” vs. “I.” Mandates add some more”I’s” into the “we” pile, but not all of us. How many? That remains to be seen. Massachusetts residents will have to choose between expensive health insurance or a tax penalty that starts at less than $300 but quickly escalates to half their expected premium. Many will buy the insurance, but others will take the penalty.

As Massachusetts “Connector” Authority chief Jon Kingsdale said, “There’s good evidence, whether it’s buying auto insurance or wearing seat belts or motorcycle helmets, that mandates don’t work 100%.”

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Democratic Debate Reaction: Health Mandates Are a Bug, Not a Feature

November 16, 2007

Hillary Clinton and John Edwards may have attacked one another last night, but they’re in agreement about the health care mandate issue – and that’s unfortunate. Most Democratic health reform plans include mandated coverage, and that’s a mistake on both policy and political grounds (although the Edwards plan offsets that somewhat with some interesting use of public insurance).

The Las Vegas Democratic debate was long on play-acting, short on substance. Meaningful exchanges about policy were hard to come by, and only three come to mind: Clinton vs. Obama on Social Security, Clinton vs. Obama on health mandates, and Clinton vs. everybody on her Iran vote.

Re health mandates, Obama may well be on the right track. When Clinton boasts, as she did last night, that her plan provides universal healthcare, what she’s not saying is that it does that by punishing people who don’t pay usurious prices to private companies in order to obtain coverage. Obama had the right response, althouch he expressed it in a passionless and somewhat detached way.

The New York Times is correct when it says that “many experts agree that that without a mandate, some people would not get coverage.” In addition, a voluntary enrollment plan will suffer from “adverse selection”: The sick will be more likely to enroll than the healthy, which will make the plan financially unstable.

But I disagree with many of my fellow “health wonks” on mandates. I’ve said they’re the wrong solution. They address the “selection” problem, but only partially. Compliance will continue to be a problem under the “mandate” approach unless fairly Draconian enforcement rules are put in place. (That’s what Obama was alluding to with his “garnishing wages” comment, which many viewers may not have understood.)

Secondly, mandates could become a political disaster. They could turn a Democratic political positive – public frustration with healthcare – into a negative. It’s easy to picture the Republican candidate talking about “nanny state” rules that “invade your privacy and seize your wages.”

No health plan will succeed if it forces Americans to overpay for insurance, on the hope that selection issues and other initiatives bring prices down in the future. It makes more sense to provide every American with a basic government-funded health plan. From there, policy options might include trading plan credits for enrollment in a private plan, or the purchase of supplemental private insurance.

But mandating that Americans buy insurance from private companies is a political and policy mistake. It’s true that mandates are the conventional wisdom today – but then, so was the wisdom of Massachusetts’ mandate-driven health reform initiative. We disagreed then, and said that the “Massachusetts miracle” would have serious problems. It now appears that – sadly – we were right (see here and here and here).

It remains to be seen whether mandates are a “feature” or a “bug” in the Democratic platform.