Wednesday, August 27, 2008

Fifteen days of blogging for health care reform: A Primer on the Obama Healthcare Platform

Guest post by Skylanda.

Tomorrow, in Denver, Barak Obama will take the stage to accept the nomination for the Democratic ticket for presidency. I will be there along with Americans from all over the nation, converging on a mile-high city that could not be more dead center of the country. Not a bad metaphor for Obama: a man who sometimes seems to walk so far above petty politics that even the swift-boaters haven’t had the juice to knee-cap him yet, and who seems to so thoroughly occupy middle-of-the-road America that the progressive left may be wondering - like I am - what exactly happened between his solemn promises of change and renewal.

So it might be a good time to take a moment to look at Obama’s health care platform through the lens of the issues and reforms I’ve brought up over the last two weeks. A thorough but sound-byte summary of the platform is available here, and if you really want to want knock yourself out cold, you can read the whole document in all its multi-page PDF glory here.

First, let’s examine the overarching, definitive issues.

Does he propose a single-payer system? No, frankly, he does not. But he cracks the door to some intriguing possibilities. His opening proposal is for a new national health plan available for all Americans to buy into (yeah, I know - if you could afford it, you’d have bought already). It includes clauses for subsidies to folks who cannot pay outright for this option, and promises affordable premiums, copays, and deductibles. Who would provide this insurance plan? Well, this is a little nebulous, but if you read the finer print, it appears that it would be administered via private insurers who contract to federal government. So: more access, still through individual contributions to private corporations. It has a certain ring to it - you get a certain sense that this might be a slow move toward a central, national system that could evolve into a single payer - and yet it lacks moxie. And it does nothing to address the question of why federal money should be going to private insurers in the first place.

Does he use the magic p-word? “Portability” makes a prominent (double-size header font!) appearance in the language of the Obama platform. Specifically mentioned is the problem of moving job to job, and the proposed answer is that through this new national health plan, you could keep your insurance through those transitions. Not mentioned are any other moments of salient relevance to portability: moving states, turning eighteen, getting divorced, suddenly making enough money to get booted off the Medicaid rolls, or, saying, losing a job altogether. I like that the word has entered the common vocabulary on a national platform; I’m not terribly pleased that the Obama platform would be satisfied with a “portability” that applies to only a fraction of cases in which it is required. A publicly funded system without full portability will incur all the taxpayer cost of a subsidized system without the streamlining benefit of single-payer sourcing - and I fear that this will end up costing more over the long haul than its own benefits are worth.

Does his platform include a provision for free small business from the yoke of paying for employee health insurance? Yes and no. Tax breaks are proposed for those that kick in for their employees health coverage, and small businesses would be exempt from a proposed requirement to tax commercial enterprises that do not offer employee health care. This is a move in a good direction, but it radically fails the fundamental task at hand: firmly and permanently extricating health benefits from employment.

Does he emphasize patient safety as a means of increasing patient confidence and reducing malpractice suits? Yes, and he proposes a steep investment into electronic medical records (though as a separate, not adjunctive, issue to the question of patient safety).

Does he acknowledge the role of prevention and public health? Yes: “Too little is spent on prevention and public health.” Good enough for me.

And then there’s some interesting details…

Investment into “Comparative effectiveness research.” You can read the detail on your own, but the content of what is proposed here already exists in several form - the most well-respected of which is the Cochrane collaboration. If the Obama camp failed to notice its existence (or thinks it can outdo Cochrane), it has another think coming.

“Millions of Americans are uninsured or underinsured because of rising medical costs.” I suppose one does not need a macro-economics lecture wrapped up in campaign promotional material, but statements like this belie a na├»vete about the root causes of lack of access - things like a private insurance industry which relies on stock market investment and high interest rates for profitability and raises premiums when those do not come through; a growing disparity between rich and poor; monopolistic practices and obscuring of cost which disallow free choice (that whole “free market“ thing that we love so much in this country) in choosing providers and products; and a whole host of other complications.

Requiring that “providers that participate in the [federally supported plans] utilize proven disease management programs.” Though this sounds like a good, solid prop for evidence-based medicine, the wording raises some hairs on the back of my neck. Proven protocols exist for common and quotidian diseases like diabetes, high blood pressure, and cholesterol. Treatment algorithms are far less established for diseases like cancer (especially the rarer types). Some diseases simply require far more flexibility, ingenuity, and nuance - not a federal mandate that straitjackets them into narrow protocols with compliance enforced by the threat of yanking reimbursement.

And then there’s a few red flags…

Demanding “mandatory coverage of children” without explaining how he plans to enforce that mandate. The paragraph following this edict notes an emphasis on expanding S-CHIP and Medicaid (which both disproportionately cover children) as “critical safety net(s),” but fails to make anything other than a threatening overtures in answering the question of how to mandate insurance for a majority children. What plans do they have for the uninsured child - turn the case over to CYFD, throw the parents in jail for lack of compliance? It is not clear what “mandatory” means in this context. Aaah, the great unfunded mandate: the same no child that was left behind under the Bush education plan would be left behind once again with the Obama health care plan.

Promising comprehensive benefits by citing “maternity health” as one of the covered aspects of the proposed national health care plan. Why not just go and call it what most providers call this sort of stuff: reproductive health. Ah yes, because that might imply that we are going to cover birth control and abortion - two words which make absolutely no appearance on the Obama platform‘s exhaustive leading page. *sigh*

In summary, the Obama platform on health care reform is ambitious and far-reaching, but still far from aligned with the vast majority of points made here over the last couple of weeks. Will I vote for him? Yeah, I will. He’s our man, whether we want him or not, and his vision for health care reform at least leans in a tenable direction. This platform is a starting gate, a flawed and imperfect one, but a place we can work from nonetheless.

As for McCain - because you might be wondering - you can sum up his proposed health care policy in four words, and so I will:

More. of. the. same.

On to Denver…

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.