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Presidential Candidates' Health Care Reform Proposals

In the May/June issue of States in Action, we described presidential candidate John Edward's health reform proposal. In this issue, we discuss the early outlines of a plan by Republican candidate Rudolph Giuliani and a detailed reform proposal by Democratic candidate Barack Obama.

Giuliani Proposal: The candidate has promised to offer details of his market-based proposal as the campaign continues. Thus far, he has revealed the plan's key feature: shifting "tens of millions" of people from employer-sponsored group health coverage to the individual insurance market. [1] Elements of the plan include:

Strategies to Encourage Purchase of Private Insurance:

  • allow people without employer coverage to exclude from taxable income up to $15,000 to help them purchase health insurance;
  • offer a health insurance credit to low-income people, which can be used with employer contributions, Medicaid, or other sources to help them purchase insurance;
  • enable individuals and firms to avoid regulations imposed on insurers in their home state by purchasing a policy from an insurer in a less-regulated state. Examples of such state regulations include requirements that insurance policies include benefits such as mental health care and restrictions on the use of health status in setting premiums;
  • expand use of health savings accounts by simplifying related rules and regulations; and
  • offer states block grants to encourage innovation, reduce costs, enroll already eligible uninsured people, and address adverse selection (when high-risk people disproportionately enroll in coverage).
Cost Containment Strategies:
  • promote transparency of price, provider qualifications, and health outcomes to enhance competition and improve value; and
  • reform the medical liability system to reduce the practice of "defensive medicine" that drives costs.
Health Improvement Strategies:
  • public–private partnerships would invest in and set standards for health information technology intended to reduce medical errors, improve efficiency, and detect health threats;
  • new, unspecified initiatives would promote healthy lifestyles and wellness programs; Medicaid payments would be tied to a state's success in promoting preventive care and tracking obesity for children; and
  • streamline the Food and Drug Administration evaluation process for new drugs.
Obama Proposal: Barack Obama's health reform proposal is comprehensive and multi-pronged, building on our current private and public health care system. It includes strategies intended to provide access to affordable, comprehensive, and portable coverage to all Americans; reduce health care costs and improve quality of care; and promote prevention and strengthen public health. Elements include the following:

Coverage Expansion Strategies:
  • requires employers that do not offer coverage to contribute a percentage of payroll toward a national coverage program;
  • expands Medicaid and SCHIP eligibility;
  • creates a new national public insurance program offering coverage similar to that in the Federal Employees Health Benefits Program (FEHBP) to individuals and small businesses, with guaranteed eligibility;
  • offers premium subsidies scaled according to income;
  • establishes a National Health Insurance Exchange whereby Americans can purchase private health plans or the new public program. Participating plans must guarantee issue, cannot vary rates by health status, and must meet minimum benefit requirements; and
  • requires all children to have health care coverage, and extends the age of dependents in family coverage to 25.
Cost Containment and Quality Improvement Strategies:
  • establishes a reinsurance program whereby the federal government reimburses employer health plans for a portion of catastrophic costs;
  • requires health plans participating in the new public plan, Medicare, and FEHBP to utilize disease management programs and supports care management, team care, and medical homes;
  • promotes transparency by requiring hospitals and providers to collect and publicly report cost and quality data, and by requiring health plans to disclose the portion of premiums used for patient care (and require them to pay a reasonable share for care instead of profits and administration);
  • requires providers to report preventable medical errors, establishes an independent institute to guide research on comparative effectiveness and dissemination of best practices, and rewards providers that achieve performance thresholds on outcome measures;
  • holds hospitals accountable for health care disparities across different populations;
  • supports and expands the capacity of safety net hospitals and providers;
  • strengthens antitrust laws to prevent health carriers from overcharging physicians for malpractice insurance, and promotes new models for handling physician errors;
  • invests $10 billion a year over five years to broaden adoption of standards-based electronic health information systems, including electronic health records;
  • reduces drug costs by allowing Americans to purchase medicines from other developed countries, increasing use of generic drugs, and allowing direct negotiation with drug companies for the Medicare drug benefit; and
  • eliminates subsidies to Medicare Advantage plans (the private plan alternative to fee-for-service Medicare).
Prevention and Public Health Strategies:
  • rewards employer worksite interventions such as health promotion programs, onsite clinical preventive services, exercise facilities, and others;
  • promotes school-based health promotion through increased funding for physical education, grants for screening programs and clinical services, and other steps;
  • increases funding to expand the primary care and public health workforce through loan repayment, adequate reimbursement, grants for training curricula, and improved work conditions;
  • requires coverage of clinical preventive services in Medicare, Medicaid, SCHIP, and the new public plan, and increases funding for community-based preventive interventions; and
  • emphasizes greater collaboration among different levels of government and with private partners to develop public health strategies and expand research, align funding mechanisms, establish interoperable communication networks, improve disaster preparedness, and other steps.
[1] "Giuliani Health Proposal Seeks Individual Coverage: Candidate to Unveil Market-Based Plan Easier on Employers," Wall Street Journal, June 7, 2007.

For More Information
See: Henry J. Kaiser Family Foundation Health 08 Web site,

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