Candidate Healthcare Plans: What's in Store for Docs & Patients?

HEALTHCARE POLICY PROPOSAL OF BARACK OBAMA AND JOHN MCCAIN

Our presidential election is only days away, 48 million people in America are uninsured and healthcare costs are rising 2-3 times faster than our nations GDP. Where will America’s healthcare system be in 5 years? Welcome to ReachMD’s monthly series Focus On Public Health Policy. This month we explore the many questions facing healthcare today.

Guns or butter, a chicken in every pot, healthcare for every American, fact or fiction? You are listening to a special program on healthcare policy on ReachMD XM 157, The Channel for Medical Professionals. I am Dr. Bill Rutenberg, your host, and with me today is Dr. Aaron Carroll.

Dr. Carroll is an associate professor of pediatric and director of the Center Of Health Policy And Professionalism research at Indiana University School of medicine in Indianapolis. Today, we are discussing the healthcare policy proposal of John McCain and Barack Obama.

DR. BILL RUTENBERG:

Welcome Dr. Carroll, thanks for joining us.

DR. AARON CARROLL:

Thank you for having me.

DR. BILL RUTENBERG:

I know you like writing about medical myth. With 700 billion dollars going to bail out Wall Street, how likely is it that you be adding healthcare reform and expanded coverage of the uninsured to your myth list?

DR. AARON CARROLL:

You know, there are days when I walk between real pessimism and real optimism and right now with a 700 million dollar bail out, it's looking pessimistic. On the other hand, if the economy really tanks and people cannot effort health insurance, it will have to have it because I think it is going to take to some extent a grassroots movement of enough people, especially people in the middle class, who are feeling the pinch from health insurance to actually start making that the issue they vote upon and if things get really bad, it is possible that that may be how they vote and how they elect their congressmen, how they elect their senators, and if that is enough of a movement, there actually likely may be some significant reform.

DR. BILL RUTENBERG:

I never thought of it on those terms but it is like if we get really a strong recession or depression and the middle class cannot afford health insurance, then everybody is going to want it from the government.

DR. AARON CARROLL:

That is right. In the event when there was a great depression, that is when we all suddenly started having huge social programs and <_____> getting us out of it and there was a real crisis of sort of the elderly becoming very, very poor in the 60s and 70s because of increasing healthcare cost, that is when Medicare and Medicaid got passed. To some extent, it may take a crisis of these bad proportions to sort of force everyone to do something about it.

DR. BILL RUTENBERG:

Have you seen any change or shifts in the proposals coming out of either camp based on this new crisis in our financial markets?

DR. AARON CARROLL:

No and unfortunately that is very disappointing because you would imagine that people would realize that, you know, you have to change your proposals to fit the world the way it is, not sort of the way you wish it would be and it is disappointing about our politics in general that they sort of had this stake out that claims in the sand if they got the claims about a year ago and now they just have to stick to it no matter what or they just lose face or whatever else matters to some extent in politics but I have not yet seen either candidate who is making any changes based upon these changes in the economy, although I think I did see a new story today that Barack Obama might have admitted that some of his goals might not be attained if they have to give 700 billion dollars in a bailout but not specifics as to which one.

DR. BILL RUTENBERG:

I would like to talk about some of the specifics and differences in their policies. If we could talk perhaps first with coverage, do you think that there is going to equal care, equal protection under the laws so to speak?

DR. AARON CARROLL:

I do not know if either one is going to achieve what they say in terms of coverage but I think that there is a big difference. I think that Barack Obama’s plan is definitely more concerned with expanding coverage and expanding it quickly than John McCain’s is. He proposes significant increases to the safety nets of Medicaid and SCHIP. He proposes increasing, the sort of, the pool, which by allowing people to buy through the federal pool, sort of increasing the ability of many Americans to purchase health insurance and providing subsidies to help many more Americans get insurance. Probably, he is saying he believes everybody can get insurance. John McCain is, I think, focused more on cost and on to some extent reducing the cost of most Americans for health insurance, moving towards more medical saving accounts, moving to the ability of private individuals to buy insurance more easily, and he talks about covering people with prior conditions and to some expanding coverage, but he is very vague and he even will admit that he sort of thinks that that should be done on a state by state level and they will decide it how to do. How that would actually happen, you know, your guess is as good as mine.

DR. BILL RUTENBERG:

Regarding cost, I saw a report in the Wall Street Journalist recently that Obama’s plan, again we were talking trillions, but Obama was 1.6 trillion over 10 years and McCain 1.3 trillion over 10 years. Is that the ballpark you have sought of been working on?

DR. AARON CARROLL:

That is what I have seen, I think that, you know, both of them are short of you, you know, dreams.

DR. BILL RUTENBERG:

Dreams to the low end?

DR. AARON CARROLL:

It may be actually to be honest, because neither one of them addresses the real problem which is cost containment. How do you make healthcare cost significantly less in the United States? As we see it, you know, the fact there you know healthcare cost per person in this country are 2-3 times what they are in every other country in the world. As a percent of our GDP, it is significantly higher than every other country in the world, and it is increasing far faster than inflation. How do we stop that? Neither one of them puts forth sort of any plan to do that and so therefore just by definition, if you increase coverage you are going to increase the cost and if you are going to cover significantly more Americans, it is going to be significantly more expensive and there really is no explanation of how they are going to achieve any type of administrative overhead benefits or any type of collective bargain, you know, benefits or any type of large risk pool benefits that you would see in other countries and so I do not understand how they are making claims towards cost containment and in fact, they do not think they are because they saying it is going to cost a lot of money.

DR. BILL RUTENBERG:

Give me the Aaron Carroll 5-point plan to save cost.

DR. AARON CARROLL:

Mine, to be honest, I think you know this is going to brand me a radical and I have spent years researching this. I think that we need to move towards a plan like Medicare for all. I think that we need to recognize that the most efficient in terms of overhead medical insurance in this country is Medicare and that if we just give up, everybody got health insurance the way Medicare does, we would achieve the economies of scale. We might be able to do some collective bargaining. We could start to publically address how we are spending money and make decision as a country together, how we are going to pay for certain things and how much we are willing to spend, and we could start effectively using money. Insurance works by taking money from healthy people and giving it to sick people, and I know a lot of people do not like to hear that but that is how insurance works. When you get in a car accident, your car is fixed by the people who did not get caught in car accidents, and when you get sick you are paid for by the healthy people. The problem with the way that we have set up is now is that the government pays only for the most expensive people. The poor, the soldiers, and the elderly, so that everybody else gets to be in another pool with private insurance. If we could take the money from healthy people, who are now covered by the private insurance, and actually shift it over to the people that need it, the elderly and everybody else, it will be a much more efficient system.

DR. BILL RUTENBERG:

Regarding cost containment, why cannot we buy drugs from Canada?

DR. AARON CARROLL:

You know that is a phenomenal question, especially since it makes no sense because a significant number of pharmaceutical companies are international. We import a tonne of drugs already. The idea that we can import them from Europe or somewhere else where they are based, but not from Canada, because one is safe and the other is not is short of ridiculous. I can tell you the reason why, I mean the legitimate reason why is because they will cost less and therefore the pharmaceutical companies would make less money and to rule out being what not we have been forbidden from doing so, but there is no safety real reason and there is no other really good reason, other than the fact that it would change sort of the agreements that have already been made with pharmaceutical companies.

DR. BILL RUTENBERG:

What is missing from the healthcare proposals of the 2 candidates?

DR. AARON CARROLL:

I think it in general what happens every election season is that all the candidates, all of them, are guilty of this promise, you know what I am going to do? I am going to increase the quality of your healthcare. I am going to make sure that more people get it and I am going to bring down the price and that is crazy. You know that defies all economic theory. You know you can increase access, you can increase quality, or you can reduce costs, and perhaps you can get 2 of the 3, but you cannot do all at once It is just not possible and yet they promise the moon every time. I think that what they are doing wrong, what they can do for us is that they should just appeal to which of the things they want to do. I think that in general, Obama is much more interested in increasing access and perhaps in, you know, increasing quality through increasing access than he isn't reducing cost, although he would certainly like to do all three. I think John McCain is much more looking at sort of the cost average Americans and thinks I can reduce the cost of the insurance to individual Americans more and I think that he, you know, he talks about quality but I do not think that he is as consumed with, you know, we gotta to increase coverage over he 4700 million, now 45 and so million uninsured and if they would just sort of say I am more for access, or I am more for cost, or I am more for quality, we could make a decision a little more rationally about what as the United States we think we need to do now. The problem is by short of promising the moon every time we wind up getting nothing.

DR. BILL RUTENBERG:

Let us turn the table little bit. The audience that we are talking to are primarily primary care physicians, under whose proposals/polices will the doctors be better off in terms of regulation, red tape, the hassle factor, and even compensation?

DR. AARON CARROLL:

I can probably see little difference in either plan because the big tenets of both of the plans is that we do not want anything to change if we do not want to, and since most Americans are resistant to change, I think most will retain the insurance that they have, meaning that whatever you deal with the insurance companies yesterday, will be the same way that you deal with them tomorrow. However, you were reimbursed yesterday, is likely how you will be reimbursed tomorrow. Neither one of them has specific differences in plans of how they are going to change Medicare reimbursement or Medicaid reimbursement and especially since that is at the state level, it will certainly how the private insurance companies are going to reimburse you and none of them offers any type of plan, which is going to significantly reduce the burden of your billing or the administrative overhead. So, I think likely there is probably little difference in the 2 with respect to how it will actually impact primary care physicians.

DR. BILL RUTENBERG:

Another area I am interested in is physician shortages that are being talked about again. You are a pediatrician. You are an expert on healthcare polices and you teach residents, I understand about career development. Recently, it was published that primary care doctors are going concierge in greater numbers than ever, new graduates are shunning primary care with only 2% of graduating residents entering into internal medicine, which is at an all time low. Is there anything in any of these proposals to stem the tide? Is there a policy change needed that these candidates need to address if they want to have a sufficient supply of primary care physician in the United States?

DR. AARON CARROLL:

Yes, I do not think that either one is addressing it but it is definitely necessary. This is one of the things that happen in a “free market system” and when you have no regulation and for good or for bad, this is what happens. Physicians have absolute authority or autonomy to decide how and where they want to practice, and they are choosing fields, which to some extent make more money and they are choosing fields which might have a better lifestyle and they are choosing fields, where they might want to practice in the areas where they want to be, and if we want to have a “totally unregulated free market system” this is what is going to happen, until we sort of address the idea of well if you want more people are going to primary care, you gotta to entice them, either through higher salaries or through some other benefits, be it loan repayment or what not. We actually have to settle with the system and make primary care more appealing. We have to make it more appealing in someway for the doctors who want to practice in the areas that are underserved and you have to sort of embrace the idea that we might have to actually regulate the system and how many physicians can go into a certain field, if we want to address those issues if you are absolutely not willing to make those kinds of steps and truly want to leave it to free market this is the end of the outcome.

DR. BILL RUTENBERG:

I would like to thank Dr. Aaron Carroll, who has been my guest for this special program on Healthcare Policy on ReachMD XM-157, The Channel For Medical Professional.

I am Dr. Bill Rutenberg and we have been discussing the healthcare policy proposal of Barack Obama and John McCain. I invite you to listen to our on-demand program library by visiting us at www.reachmd.com. If you have comments or suggestions, call us at 888-MD-XM175.

Thanks for listening. Until next time, I wish you good day and good health.

You have been listening to Public Health Policy in America, a special ReachMD XM-157 interview series with our nations top thought leaders in public health. This month ReachMD XM 157 will be discussing the many issues challenging public health policy in America. For complete scheduled of guests and programming information visit us at www.reachmd.com.