With the release of Michael Moore’s “Sicko” health care has become a hot issue in national and local politics, and the debate is begining to heat up amongst the presidential contenders as well as the candidates to succeed Marty Meehan as Congressman from the Fifth Congressional District. A pretty interesting story in today’s Washington Post goes into some detail on the debate amongst the Democratic presidential campaigns, and how “health care incrementalism” appears to be winning, at least nationally, amongst the Democratic candidates. The Post article frames the Democratic debate as an idea war between MIT Professor Jonathan Gruber and Dr. Ezekekiel Emanuel, with Emanuel being the proponent of blowing up the existing system and Gruber favoring incremental change. Gruber was a major force in writing the new Massachusetts health care law, which is getting significant national media coverage. The Post refers to an exchange between Gruber and Democratic candidate John Edwards, which Gruber characterized as follows:

He told Edwards that whatever the merits of Emanuel’s idea, it just would not be politically viable. Instead, Gruber argued for a more incremental approach, like the one in Massachusetts he helped write. Its central elements would be providing subsidies to people who are unable to pay for health care, increasing the number of those who are enrolled in public programs such as Medicaid and creating a public agency to help anyone ineligible for the programs buy health insurance.

Gruber, although a health care expert, essentially defends his approach on the basis of political viability, not on the basis of policy.

“Plans which minimize the disruption to the existing system are more likely to succeed than plans that rip up the existing system and start over,” said Gruber, who has consulted with the three leading Democratic campaigns about their health plans. “It doesn’t take a genius to see that. That’s not to say that plans ripping it up wouldn’t be better — I just think they’re political non-starters.”

And who is winning the debate?

To move toward universal coverage, Edwards, Clinton and Obama have approaches that borrow from the Massachusetts model. That plan, regarded as one of the nation’s most innovative, took key elements of the 1993 Clinton plan and made them practical politically — so practical that the plan was enacted in 2006 by a Democratic legislature with support from a Republican governor, 2008 presidential candidate Mitt Romney.

Obama alone appears to reject the individual “mandate” that is the backbone of the Massachusetts plan.

Obama aides argue that people fail to buy insurance because they cannot afford it, not because they do not want it, so the senator from Illinois has not included a similar mandate in his proposals, focusing instead on reducing costs. Political caution in part motivated the decision, concede some Obama advisers who worry that such a mandate might be politically difficult for a president to enforce.

And what of something that all candidates tout, the holy grail of cost containment, without which, in my opinion, all plans ultimately fail. Are we deluding ourselves on what is needed to really contain health care costs?

But some health experts argue that it is hard to imagine the savings the Democrats are touting without some painful measures, such as allowing insurance companies to restrict the kind of procedures or the choice of doctors that Americans have. “There is an idea you can somehow do all these things controlling costs without anybody doing anything they don’t want to do,” said John Sheils, who studies health-care plans at the nonpartisan Lewin Group. “These are tough questions.”

And so the debate is joined. Emanuel has derided the health care caution being shown by the national candidates.

Ezekiel Emanuel has not been impressed by the candidates’ efforts on health care. When Edwards released his plan in February, he blasted it in an e-mail to one of the candidate’s aides, saying it was hard to figure out why someone seeking the Democratic nomination was backing a health-care approach crafted by Romney, a Republican.

“I don’t think they’re very bold,” Emanuel said. “I don’t actually think they solve the problem.”

And what does Emanuel see as the right prescription? It is his view that the system is broken, and that short term fixes will eventually be destroyed by runaway costs. In a separate Post article Emanuel says of the incremental approach to health care:

They build on what everyone agrees is a broken system. Ultimately, they prop up the sagging employment-based insurance system, with all its inefficiencies and inequities, and preserve the second-class income-tested programs such as Medicaid. By focusing on covering the uninsured, they fail to address either administrative inefficiency or long-term cost control. Consequently, in the short run they require ever more money to cover the uninsured, and in the long run the unabated rise in health costs will quickly revive the problem of the uninsured.

Can Emanuel point to a program that might appear to be a success, but in fact has not had the impact envisioned. Yes, he point to The State Children’s Health Insurance Program (SCHIP) as an example. He writes in the Post that

The State Children’s Health Insurance Program (SCHIP) provides a good example of the toxic interactions between public and private coverage. When it was enacted in 1997, SCHIP filled a hole, offering insurance to children whose parents earned too much to be covered by Medicaid but not enough to buy private health insurance. By 2005, 6 million children received health coverage through SCHIP. But SCHIP has had only a small impact on the overall number of uninsured children. In 2006, there were nearly 9 million uninsured children, compared with 10 million uninsured in 1997. Why? As costs rose, some companies stopped offering insurance, others dropped coverage for dependents, and others raised employee contributions to the point where some workers preferred covering their children through SCHIP.

Emanuel makes a pretty good point here, and one that goes to the ultimate key to success, cost containment. What does Emanuel suggest? A five point plan of essential reform!

· Get businesses out of health care. Health care is not part of their core competencies but something they use as a part of labor relations. It creates job lock and distorts employers’ hiring and firing decisions.

· Guarantee every American an essential benefits package. This package — modeled on what members of Congress get — should be provided by qualified plans that would receive a risk-adjusted payment for each enrollee. Americans could choose their health plans, with guaranteed enrollment and renewability; “cherry-picking” and “lemon-dropping” would be minimized.

· The universal basic package should be financed by a dedicated tax that everyone pays, such as a value-added tax.

· Administer the program through an independent National Health Board and regional boards modeled on the Federal Reserve System. They would oversee health plans, define the benefits packages and, through strong incentives, facilitate adoption of patient safety measures and electronic management of medical records.

· Establish an independent Institute for Technology and Outcomes Assessment to systematically evaluate new technologies and quantify their health benefits in relation to their costs. These evaluations would be used by the National Health Board and health plans.

Quite a program, and one that truly does change the existing system. Has the political experience with the Clinton Health Care proposals made our candidates to timid on health care? Should political viability be a key barometer for the candidates as they fashion health care proposals for the country? Key questions locally and nationally. I have included a raucous video clip of Michael Moore being interviewed by Wolf Blitzer on CNN, in which Moore really tees off on Blitzer. Great viewing, and without question some pretty poor TV etiquette from Moore, but I did enjoy the media being placed on the hot seat for a change. View that clip here.

Todays Washington Post story is at this link.
The second Post story is at this link.