06 January 2008

Republican candidates talk health care

Republican talking points on health care as displayed at the New Hampshire debate last night:
(List points and discuss which elements are correct, which need rebuttal. Test Monday!)
DR. TIM JOHNSON, ABC MEDICAL EDITOR: In general, Republicans have criticized Democratic proposals for health care reform as radical expansions of the federal government's role. But many health care experts say that it is actually the Republicans' emphasis on individuals buying their own policies versus getting their insurance through employers that is a more radical change. And it raises concerns. Individual policies can be more expensive for the same coverage because of administrative overhead and sales costs.

Group policies like those provided by employers can bargain with providers for lower costs and do a better job of monitoring quality. Medical professionals caution that individual insurance may sound good on paper but it usually turns out to be very difficult for people, on their own, to find quality policies at the right cost.

GIBSON: ... We're the only industrialized nation in the world that doesn't insure all of our citizens. If we can afford a trillion-dollar war in Iraq, why can't we afford medical insurance for everybody?

GIULIANI: The reality is that, with all of its infirmities and difficulties, we have the best health care system in the world. And it may be because we have a system that still is, if not wholly, at least in large part still private.

To go in the direction that the Democrats want to go, much more government care, much more government medicine, socialized medicine, is going to mean a deteriorated state of medicine in this country. I mean, I said, jokingly, in one debate, if we go in the direction of socialized medicine, where will Canadians come for health care?

GIBSON: But do you all agree that we have the best health care system in the world?

MCCAIN: Now, tell me when people get sick where they come to to get health care...

GIULIANI: Charlie, that doesn't mean it shouldn't be improved. And I think that the notion of people buying their own private health insurance is a very good one, so long as a lot of them do it. Only 17 million Americans right now buy their own health insurance. If 50 million Americans were buying their own health insurance, because it would be just as tax advantageous to do it that way, and we had a health savings account, people -- economists believe there'd be a 30 percent to 50 percent reduction in the cost of health insurance, and quality would come up. The only thing that reduces cost and increases quality is a significant, dramatic, large consumer market, not government control.

GIBSON: You all have proposed free market, consumer-purchased insurance. And you all talk about giving tax deductions for buying insurance. Let me do a little math. The average family employer-provided insurance, when the company's buying, it's $13,000 a family. Now, you talked about a $15,000 to $20,000 deduction -- right? -- for people buying their own insurance. If you take a median-income family of $62,000 in this country, you've just saved them $3,000 on their taxes. That doesn't come close to buying an insurance policy.

MCCAIN: Sure. And next year, if you continue 10 percent inflation associated with it, it'll be even further away. And the next year after that. Because the problem with health care in America, it's not the quality. It is the inflation. And in all due respect to your expert that we just saw, he's talking about the wrong aspect of this issue. The right aspect of this issue is inflation, if we could get it under control and get it reduced so that health care costs are reasonable in America, then those people will be able to afford it... But we have to make the recipient of the health care more responsible. We have to have outcome-based results for health care. We have to emphasize wellness and fitness. One of the most disturbing things in America is the increase in diabetes, obesity and high blood pressure amongst younger Americans. So we have to award wellness and fitness...

But, again, you made a statement about European nations, they all get health care. Well, some people here in New Hampshire have been to Canada. I don't think they want that system.

ROMNEY: ... [after boasting about the Mass. plan] And where the doctor -- good doctor was wrong is that it's true the insurance companies don't want to sell policies to one person at a time. It's expensive. We established what we called a connector, a place where individuals could go to buy policies from any company, and that connector would in turn send their premiums on to those companies. So the economics of scale existed. And as a result of what we did, the premiums for health insurance for an individual buying insurance went from $350 a month to $180 a month, with lower deductibles and now with prescription drugs.

We don't have to have government take over health care to get everybody insured. That's what the Democrats keep on hanging out there. The truth is, we can get everybody insured in a free market way. We don't need Hillary-care or socialized medicine.

PAUL: Charlie, you really answered the question -- you answered it in your question, because you said, "How can we afford a trillion- dollar war and we can't afford health care?" Well, that's the reason. The resources are going overseas. We're fighting a trillion- dollar war and we shouldn't be doing it. Those resources should be spent back here at home. There is an inflationary factor. We can't afford it. We do have good medical care, but the costs are so high now that our people in this country are actually going to India and getting their heart surgery done. They pay the plane ticket, the hospital and the hotel and they get it for half-price.

So it's inflation, but if you don't understand how inflation comes, we can't solve this problem. It comes from deficit financing with this war-mongering foreign policy we have. We run up the deficits. We tax. We borrow. We borrow from the Chinese. We can't borrow enough. Then what do we do? We print the money, and then you wonder where the inflation comes. The value of the dollar is down and the prices go up, where the government gets involved in certain things like housing or medical care or education, prices are skyrocketing. So you have to deal with the monetary issue to solve the problem of the medical issue.

THOMPSON: Ahem. ... So if we would stop printing so much money, we could get out of the war and provide health care to everybody.

We've got the best health care in the world. It costs more than it should. We can either go one of two ways. We can let the government take it over, and that'll lower costs, like they do in other countries. We will also sacrifice care, which nobody wants to do -- we're not going to do, in this country.

Or we can make the markets work more efficiently. There are a lot of components to that. Part of that is not just giving a tax break to the individual. That's part of it. But it's also putting them in a position to get the best prices for the care they're getting. We do that in every other aspect of our life. That's what keeps prices as low as they are. I mean, if the consumer had no concept of what the product was costing and did no shopping for it, when you could get an MRI here for one price or over here for half the price, you don't even know that to make the choice. It wouldn't work at all. So you can do that. You can open up these markets so a person can buy their insurance from all over the country. We've got various state regulations now, that, as a practical matter, prohibit that. Make the markets work.

But we're never -- let's be honest with the people. We're probably never -- if you lower costs, more people who want insurance will be able to afford it. We're probably never going to achieve total coverage. A good number of the people who are uninsured can afford it and choose not to do so. A good number of people who are eligible for government assistance, and choose -- can manage and choose not to.

GIBSON: But Government Romney's system has mandates in Massachusetts, although you backed away from mandates on a national basis.

ROMNEY: No, no, I like mandates. The mandates work.

THOMPSON: I beg your pardon? I didn't know you were going to admit that. You like mandates.

ROMNEY: Let me -- let me -- oh, absolutely. Let me tell you what kind of mandates I like, Fred, which is this. If it weren't...

THOMPSON: The ones you come up with.

ROMNEY: Here's my view: If somebody -- if somebody can afford insurance and decides not to buy it, and then they get sick, they ought to pay their own way, as opposed to expect the government to pay their way. And that's an American principle. That's a principle of personal responsibility. So, I said this: If you can afford to buy insurance, then buy it. You don't have to, if you don't want to buy it, but then you got to put enough money aside that you can pay your own way, because what we're not going to do is say, as we saw more and more people...

THOMPSON: The government is going to make you buy insurance...

ROMNEY: No, the government is going to stop...

THOMPSON: ,.. and make you pay -- I mean, the state -- your state plan, which is, of course, different from your national plan, did require people to make that choice, though. The state required them to do that. What was the penalty if they refused?...

ROMNEY: ... It actually applies to people at three-times federal poverty. They pay for their own policy. At less than three-times federal poverty, we help them buy a policy, so everybody is insured, and everybody is able to buy a policy that is affordable for them. The question is this, again, if someone could afford a policy and they choose not to buy it, should they be responsible for paying for their own care? Or should they be able to go to the hospital and say, "You know what? I'm not insured. You ought to pay for it."

What we found was, one-quarter of the uninsured in my state were making $75,000 a year or more. And my view is they should either buy insurance or they should pay their own way with a health savings account or some other savings account.

... I think my plan is a good plan that should be adopted by other states.... I would not mandate at the federal level that every state do what we do. But what I would say at the federal level is, "We'll keep giving you these special payments we make if you adopt plans that get everybody insured." I want to get everybody insured....

HUCKABEE: I think it's important to realize that the issue is not just insurance. The issue is that the whole model of our health-care system is upside down. We really don't have a health-care system. We have a disease- care system. And the insurance model that we use, we act like that if we insured everybody, we've fixed it. We haven't. Because the real problem is that our model, both in the insurance model and the health-care model, waits until people are catastrophically ill before it intervenes. And we really have to change the concept to a preventive focus rather than an intervention focus. And that means the entire system starts working on health and wellness, because 80 percent of the $2 trillion that we spend on health care goes to chronic disease. We could prevent it or we could cure it, but we don't. So it's not an issue of there's not enough money to cover people. But if a real health care system exists, it has three components: It has affordability, it has quality, and it has accessibility.

And if it doesn't have those elements, it's not a system; it's a maze. And what we have in America is a health care maze. It's built on the idea that we wait until people are so desperately ill that the cost to try to fix them is catastrophic and out of control. And no wonder we have a system that needs major, major attention. And by the way, just out of due respect, you said $1,000 for a repair. It's about $1,000 for a Kleenex at a hospital anymore. And that's why we need to have a totally different system that keeps you from going to the hospital in the first place.

GIULIANI: Charlie, a health savings account actually helps to accomplish what the governor is talking about. If somebody can put aside -- and the plans that we've been talking about include a health savings account. You'd have an exemption up to $15,000. If you could find a policy for $11,000, you can have a $4,000 health savings account. You would be able to buy some of your health care and your prevention yourself. It gives you an incentive over a lifetime to deal with wellness.

GIBSON: ... Look, if you're going to control costs, you got to do three things. You're going to limit access to technology, you're going to limit, in some way, change the reimbursement system for doctors and hospitals, or you're going to have to limit the amount of treatments. That's the only way we can bring costs down. And that's the third rail of health care. Which of you is going to touch any of that?

HUCKABEE: Charlie, that's not at all the way it is...

MCCAIN: I think that there's additional choice here: a choice of having outcome-based treatment. There are five major diseases that consume 75 percent of health care costs in America. If someone has diabetes, we should give the health care provider a certain amount of money and say, "Care for that patient. And if, at the end of that period of time, and that patient is well, we'll give you a reward." Rather than every test, every procedure, every MRI. And we need walk-in clinics, and we need community health care, and we need incentives for home health care as opposed to long-term care. In my state of Arizona, we adopted a proposal which incentivizes health care providers to keep people in home health care settings -- dramatically less expensive than long-term care. In Arizona, we have one-half the number, per capita, of people in long-term care facilities as the state of Pennsylvania.

Incentives to keep costs down, Charlie. There are no incentives in the system today.

Could I just mention one other thing? Both the attorney general of South Carolina -- I don't know why I mention South Carolina... and the attorney general of Iowa ... have sued the pharmaceutical companies because of overcharging of millions of dollars of Medicaid costs to their patients. How could that happen? How could pharmaceutical companies be able to cover up the cost to the point where nobody knows? Why shouldn't we be able to reimport drugs from Canada? It's because of the power of the pharmaceutical companies. We should have pharmaceutical companies competing to take care of our Medicare and Medicaid patients.

ROMNEY: OK, don't leave me. Don't send the pharmaceutical companies into the big bad guys.

MCCAIN: Well, they are.

ROMNEY: No, actually they're trying to create products to make us well and make us better, and they're doing the work of the free market. And are there excesses? I'm sure there are, and we should go after excesses. But they're an important industry to this country. But let me note something else, and that is the market will work. And the reason health care isn't working like a market right now is you have 47 million people that are saying, "I'm not going to play. I'm just going to get free care paid for by everybody else." That doesn't work.

Number two, the buyer doesn't have information about what the cost or quality is, or different choices they could have. If you take the government out of it to a much greater extent, you'd get it to work like a market and it will rein in cost.

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