David Blumenthal, M.D., M.P.P., director of the Institute for Health Policy and an advisor to the Obama campaign, earlier this month published a sharp critique of Sen. McCain’s health care plan in the New England Journal of Medicine. "Primum Non Nocere — The McCain Plan for Health Insecurity" identifies McCain’s proposals with the Bush administration’s health policies, and warns that the Republican candidate’s plan would decimate the current employer-sponsored health insurance system.

Of course, in one sense no surprise -- the NEJM emanates from a very liberal area, and Blumenthal is an Obama advisor. But, I think there’s something of interest here for you, regardless of who you support in the presidential campaign. McCain wants to unleash the free market to lower costs, promote choice, and improve quality... Who can argue with that? But, given the complexity of health care, moving toward that goal precipitously could create a crisis even bigger than the current banking nightmare. Blumenthal has to be seen as partisan; but there are concerns there that I wish McCain’s advisors (Doug Holtz-Eakin and others) had thought through more carefully before putting incomplete ideas out there  Not that Obama’s ideas are complete strategies either. As I’ve shared previously, I think both party platforms are worrisome for doctors and ACC. That’s why we need to engage and get involved in the final products. But this makes thoughtful reading if you extract the partisan bias. I’d be interested in your thoughts.

During last night's debate, the candidates discussed the major provisions of their health care plans. Nothing particularly surprisingly or new came out of it, but if a bill circulating through Congress is passed, a provision of McCain's plan could become more important

Sens. Max Baucus (D-Mont.) and Chuck Grassley (R-Iowa) introduced a bill last week to require employers to print the cost of health insurance on employees’ W-2 forms. Baucus and Grassley believe that this level of transparency will help consumers to be more cognizant of the rising costs of health care. Educated consumers, they say, will be more prudent and help to lower spending. 

Meanwhile, McCain would give employees (families) a $5,000 tax break on insurance they purchase, but simultaneously tax their employer insurance as income. For some employees it will be a net plus, for others, not. Either way, transparency would be key. The Business Roundtable and US Chamber, normally supportive of Republican platforms, are opposed to this because they think it will cause people to quit employer coverage and create a sicker workforce. The Washington Post and WSJ have run articles on pros and cons here.

Many economists see McCain’s plan as being about equal to Obama’s plan in covering uninsured persons, but the Lewin Group opined that it will much more expensive in the long run. Hard to say. Meanwhile, McCain pundits are claiming Obama wants to eliminate private coverage, and that’s not true. He would prevent insurers from using pre-existing exclusions and taking excessive profits; while McCain is silent there.  Trade offs.

But no matter who is elected, I think the discussion on how to move forward needs to take some time and more careful discussion.

The Congressional $700 billion fix of the Wall Street banking and credit mess might have stabilized our 401(k)s for awhile, but doesn’t leave much on the table for health care next year. Note that the SGR “fix” would add over $300 Billion to the national debt (China would likely need to loan us that, so we docs would all be working for Beijing, I guess). But, as I reported last week, major leaders in the House and Senate still believe major reforms will proceed in 2009.

Senator Kennedy weighed in on this late last week, even though he’s running his office from home in Massachusetts. His chief health reform strategist, John McDonough, told ACC this week that their reform idea would include:

• Coverage (universal or near universal coverage)
• System reform (comparative effectiveness, primary care medical home, HIT, payment reform, transparency, prevention, disparities, workforce, etc)
• Financing that doesn’t add further to the deficit (which, to me, means cuts somewhere else).

Obama plans to apply his reversal of Bush tax cuts on the over $250,000/year crowd to finance some expansion of coverage on kids. McCain will give every family a $5,000 tax credit voucher to purchase their own coverage (which offers the advantage of more choice and portability). But, he would finance those vouchers by taxing as income all employer coverage, which is now tax free to employees. With family premiums at about $13,000 a year, that would add thousands of dollars of new taxes for those who elect to continue their employer coverage. Both McCain and Obama plan to try to lower average insurance costs with better group purchasing (free market at work?), and, for Obama, with insurance reforms as well. Kennedy hasn’t said where he’d recommend getting the $$$. But, I don’t think this will be easy for any of them. [For more coverage see today's Health Affairs blog, which summed up its coverage of the candidates plans.]

The ‘free, largely unregulated market’ idea, which will be changing for Wall Street of necessity, has existed in health care much more for health insurers and industry (who more often set their own prices) than it has for doctors and hospitals (where we are largely at the mercy of what government and insurers pay). We might benefit if there was a more level playing field among all the health care constituencies, where right now we are at a distinct disadvantage to insurers, industry, and hospitals. But, there are some very bullish forces at work out there in the economy that will definitely affect health care. Need to be on our toes here… 

The world’s biggest super-collider in Switzerland, activated several weeks ago, successfully smashed subatomic particles together as designed to recreate a mini-Big Bang, and seemingly without creating a black hole, an unintended consequence that some observers feared could potentially form and swallow up our planet. Unfortunately, the black hole did manifest — not near the collider in Europe — but instead on Wall Street.

The still unresolved fiscal crisis will likely suck up a great deal of the resources needed for health system reform. ACC President Doug Weaver and I talked further about this issue on Cardiosource Video Network this week. One unexpected effect of this crisis might be that the predicted physician/cardiologist supply shortage may be less severe — people won’t be able to retire.

The black hole is also affecting the candidates’ outlook on health care. Although it was only touched upon in last night's VP debate, Sen. Obama has acknowledged some of his health and environmental priorities may have to be funded in a multi-year sequential fashion as a result of the financial crisis. Sen. McCain’s campaign has thus far said they still plan to proceed full steam ahead with their health priorities. If so, it would involve funding their way by making cuts in existing Medicare costs. That would be scary for physicians and high-cost services like imaging. Deferring big spending right now might be a good idea — both campaigns need more work on their ideas. In fact, I think perhaps 2009 should be devoted to a national ‘conversation’ about what reforms should look like, given that there won’t be much money for real implementation, and all the big strategies need work. More...