Tuesday, September 18, 2007

Clinton and Edwards on Health Care

So I've skimmed Hillary Clinton's health care plan and I've skimmed John Edwards' plan. I'm not an expert on this issue, so I'm not going to pretend that I'm analyzing every single point. What I've done below is to pick out several important differences and highlight them. It should be fairly clear where my loyalties lie by the end.

It's important that both of these proposals are just that - proposals. None of the current proposals are binding in any way, but they can be legitimately seen as statements of principle - where a candidate takes a stand and where they waffle or compromise.


There's several significant differences in the plans. You can start with the titles of the plans. Clinton's plan is titled the "American Health Choices Plan: Quality, Affordable Health Care for Every American." The emphasis seems here to be on choice, and rather than use the phrase "universal health care," she uses the awkward phrase "quality, affordable health care for every American." The difference is significant.

The document outlining Edwards' plan is titled "Universal Health Care Through Shared Responsibility." He pointedly uses this quote to introduce the plan:
“We have to stop using words like ‘access to health care’ when we know with certainty those words mean something less than universal care. Who are you willing to leave behind without the care he needs? Which family? Which child? We need a truly universal solution, and we need it now.”
Expanding Government Plans

Edwards' plan relies on an expansion of government plans that already cover millions of Americans: Medicaid and SCHIP.

Edwards' Plan: Medicaid and the State Children’s Health Insurance Program (SCHIP) play essential roles in helping low-income Americans getting the health care they need.

Edwards will strengthen the federal partnership with states supporting these programs, committing the necessary federal resources to allow states to expand Medicaid and SCHIP to serve all adults under the poverty line and all children and parents under 250 percent of the poverty line (about $50,000 for a family of four).

Edwards' approach calls for a new "public insurance plan modeled after Medicare, but separate and apart from it. Families and individuals will choose the plan that works best for them. This American solution will reward the sector that offers the best care at the best price. Over time, the system may evolve toward a single-payer approach if individuals and businesses prefer the public plan."

Clinton's plan offers no significant expansion of health care plans. The only concession is a vague line "fixing the holes in the safety net to ensure that the most vulnerable populations receive affordable, quality care." While this may result in expansion of coverage, she does not use that term and I will also not use the term in regard to her proposal.

In the Clinton plan, government's primary responsibility is not to offer expanded health care coverage, but to 'ensure' that private health care is kept affordable and to "implement reforms to improve quality and lower cost." Again, they're supposed to lower cost on private health care plans, not expand the plans that currently exist.

Clinton's plan:
will ensure that health insurance is always affordable and never a crushing burden on any family and will implement reforms to improve quality and lower cost.

At one point, Clinton does seem to offer an expansion of coverage - or rather, the creation of a new health care plan, similar to Edwards' plan, that is not Medicare. Individuals will be offered the option of keeping their health care coverage or choosing from a list of private health care options modeled after Congress' current options for health care. She makes no mention of an eventual goal of single-payer coverage. The term "single-payer" appears nowhere in her plan.

[...]the Health Choices Menu will also provide Americans with a choice of a public plan option, which could be modeled on the traditional Medicare program, but would cover the same benefits as guaranteed in private plan options in the Health Choices Menu without creating a new bureaucracy. The alternative will compete on a level playing field with traditional private insurance plans. It will provide a more affordable option, in part through greater administrative savings. It will not be funded through the Medicare trust fund.

Pre-Existing Conditions

Both plans appear to ban discrimination for pre-existing conditions.

Edwards' plan: Edwards will require insurers to keep plans open to everyone and charge fair premiums, regardless of preexisting conditions, medical history, age, job, and other characteristics. No longer will insurance companies be able to game the system to cover only healthy people. Several states – including New Jersey, New York, and Washington – have led the way on similar community rating and guaranteed issue reforms. In addition, new national standards will ensure that all health insurance policies offer preventive and chronic care with minimal cost-sharing.

Clinton's plan
: By creating a level-playing field of insurance rules across states and markets, the plan ensures that no American is denied coverage, refused renewal, unfairly priced out of the market, or forced to pay excessive insurance company premiums.

Sticks and Carrots for Business

The Clinton plan offers tax incentives for small businesses. By offering a number of schemes to trim bureaucracy and create health are efficiencies, she suggests that she can make health care more affordable and more efficient. She proposes this as an incentive for businesses to offer health care for their employees.

In return, large employers will be expected to provide health insurance to their employees or make some contribution to the cost of coverage.

"Some contribution" is a meaningless term. Similarly, Clinton does not explain whether employers would be offering subsidies to their employees to buy private health care coverage, or whether they would be recompensating the government for the cost of providing health care for their employees. There is an important and frustrating lack of specificity here.

Edwards' plan: Businesses have a responsibility to support their employees’ health. They will be required to either provide a comprehensive health plan to their employees or to contribute to the cost of covering them through Health Care Markets. In return, the Edwards plan will make it easier for businesses to offer insurance by reducing costs and creating new choices. Covering all Americans will eliminate the cost of uncompensated care. Businesses can also choose to purchase care through Health Care Markets, which will offer quality plans at low prices and with minimal administrative burdens.

The approach is similar, but Edwards is more clear about what businesses' obligation will be if they do not offer health care for their employees.

Individual Tax Credits to Buy Coverage

Both candidates offer tax credits to help individuals pay for health care coverage. The tax credits would be refundable. The Clinton plan would index tax credits to ensure that "health premiums never rise above a certain percentage of family income. The tax credit will be indexed over time, and designed to maintain consumer price consciousness in choosing health plans, even for those who reach the percentage of income limit." The Edwards plan would offer tax credits on "on a sliding scale to middle class families and refundable to help families without income tax liability." The approaches are nearly identical.

The Mandate

I've seen more than one person say that Clinton's and Edwards' approaches are similar in that they would both require individuals to carry coverage. Indeed, Clinton's plan would require individuals to carry health care insurance.

Individuals: will be responsible for getting and keeping insurance in a system where insurance is affordable and accessible.

And ditto Edwards.

Once insurance is affordable, everyone will be expected to take responsibility for themselves and their families by obtaining health coverage.

So are the two mandates identical? Hardly. Edwards mentions a mandate at the end of a long list of goals for improving health, which include:

First: Business Responsibility.
Second: Government Responsibility.

• Offer New Health Insurance Tax Credits

• Expand Medicaid and SCHIP

• Require Fair Terms for Health Insurance

• Secure the Health Care Safety Net

Third: New Health Care Markets.

Only after all of the previous steps are achieved does he call for a mandate to carry health care coverage. He makes it clear that individuals can only be required to insure themselves after the market is made more fair and more affordable and new plans are offered by the federal government.


Edwards proposes to cover every American by 2012. Clinton does not include a timeline in her plan, but has said publicly that she hopes to implement her plan by the end of her first term - 2012. She does not say whether every American will be covered by then, or if the plan will merely be in place by then.

There's lots more here than my tired brain can cover. Go look at the plans yourself. Clinton's is here. Edwards' is here. Make up your own mind. But as for me, I prefer Edwards' approach. He is unafraid to call for an expansion of government plans, and he clearly aspires for single-payer coverage. Indeed, his plan deliberately puts public and private plans against each other, with the expectation that more people will eventually choose public plans if given a fair choice on a level playing field. It's a smart idea - allowing the public to lead themselves toward universal single-payer coverage.

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