Obama vs. Romney on health care reform

[Greenbeard]

The Obama and Romney campaigns contributed dueling perspective pieces to the New England Journal of Medicine this week. In it they offered their diagnoses of the current system's problems, they laid out their vision of the path forward, and took some shots at each other.

Obama's: "Securing the Future of American Health Care"
Romney's: "Replacing Obamacare with Real Health Care Reform"

Here are their diagnoses of the problem.

Obama:

Because of you, America is blessed with the world's most talented health care professionals, who do a heroic job serving and saving our citizens. But for years you have faced a health care system that was increasingly fractured. Insurance companies had unchecked power to dictate care and cap and cancel your patients' insurance. Tens of millions of Americans were left uninsured and underinsured. Health care costs were growing at an unsustainable rate, and our delivery system rewarded quantity of care over quality of care. You were spending more of your time on insurance forms and appeal letters — and less time doing what you trained to do: care for patients. But after a century of trying, a broad coalition of doctors, nurses, hospitals, businesses, AARP, and patients helped me sign into law the Affordable Care Act.

Romney:

Unfortunately, our challenges grow worse every year. Higher premiums cut sharply into paychecks that never seem to increase. Losing a job means losing insurance coverage at the moment a family can least afford it, and those with preexisting conditions can be left with nowhere to turn, despite needing the greatest care. The sheer volume of red tape overwhelms even the most savvy consumers, while taking too much of each doctor's time and slowing innovation in life sciences. Through it all, experts continue to warn that the current path is unsustainable — that for all its frustrations, the system is becoming more expensive and will eventually bankrupt our government.

And parts of their suggested approaches to solving them:

Obama:

As you surely experience every day, we are also seeing substantial movement in the emergence of new care models. Everyone understands the limits of our current system, which rewards increases in the quantity of care, not improvements in the quality. Still, change has been difficult — and that's why my administration has been so encouraged by the response to the reforms in the health care law. Across the country, provider groups are working with us to form accountable care organizations, and more and more hospitals are moving toward bundled payments. We are partnering with hospitals across the country to prevent health care–associated infections and avoid preventable readmissions — and meeting our goals together could save $35 billion and 60,000 lives over 3 years. And we are building our health care workforce, recognizing the demands of an aging population as well as the needs of people who will become newly insured. As we move forward, we will remain a partner in working together to strengthen our system and help you deliver the best possible care.

Of course, there is more to come, since many of the law's provisions take effect in 2014, when 30 million currently uninsured people will finally begin to find affordable coverage. Our insurance market will be strengthened so insurance companies cannot deny coverage or charge anyone more on the basis of a preexisting condition, and middle-class families that don't get insurance at work can receive tax credits to finally make coverage affordable. As a result, for the first time in American history, people who lose their jobs, change jobs, start a business, or retire early will know that they can find insurance for themselves and their families.

Romney:

In the health care system that I envision, costs will be brought under control not because a board of bureaucrats decrees it but because everyone — providers, insurers, and patients — has incentives to do it. Families will have the option of keeping their employer-sponsored coverage, but they will also be empowered to enjoy the greater choice, portability, and security of purchasing their own insurance plans. As a result, they will be price-sensitive, quality-conscious, and able to seek out the features they want. Insurers will have to compete for their business. And providers will find themselves operating in a context where cost and price finally matter. Competition among providers and choice among consumers has always been the formula for better quality at lower cost, and it can succeed in health care as well.

To achieve this aim, we must end tax discrimination against persons purchasing insurance, we must strengthen and expand health savings accounts, and we must establish strong consumer protections. The result will be patients who can confidently choose the coverage that is right for them, who know and care what health care costs, and who reward providers that deliver effectively. For this choice to be meaningful, insurance market reforms must promote competition by eliminating onerous mandates, facilitating purchasing pools, and opening up an interstate market. Regulation must prevent insurers from discriminating against people with preexisting conditions who maintain continuous coverage.

I was struck by a few things in reading these.

1. The two candidates agree on the need to fix the individual insurance market for people who don't have employer-sponsored insurance. They're both interested in seeing a competitive market with "strong consumer protections," to borrow Romney's words. This shouldn't be surprising as the mechanism for doing that (new marketplaces dubbed "exchanges") was pioneered in Massachusetts under Romney and is now being disseminated around the country by Obama.

2. Romney missed his audience. In a piece aimed at doctors and other readers of the NEJM, Romney identified changing the tax treatment of health insurance and changing the rules around HSAs as the big reforms that are needed. He wrote of a world in which "everyone — providers, insurers, and patients — has incentives" that work, which sounds great. But it's not clear that he actually understands or wants to address the bad incentives that providers currently face.

3. Only one candidate seems interested in fixing health care. The current system is broken and not just because so many people don't have health insurance (obviously that will be less of a problem in a few years), but because the ways we pay for and deliver health care are flawed. Obama, to his credit, has been focusing on encouraging better models of care that pay doctors and hospitals for the right things not the wrong things, and encourage quality over quantity. Fixing the deficiencies in the insurance system is important, but so is building a health care system that gives doctors the support they need to provide patients with the kind of care they need, in the way they need it.

So let's talk. Who do you think has the better all-around approach to reform?

 

[driveby]

Obama wants single payer, Romney doesn't.........

 

[Greenbeard]

Obama wants single payer, Romney doesn't.........

If that were the case, it doesn't make much sense for Obama to be seeding the creation of new private payers. Or creating new private-only insurance markets. Or subsidizing the purchase of private health insurance.

The reality is that no one--outside of Vermont--is particularly interested in single-payer at present.