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“After 1994,” she said, “when people asked me if I was going to give up on healthcare reform, I always had the same answer: Why would I give up on America and the American people? For so many years, I have listened to their stories. I carry these stories with me every day. I believe every man, woman, and child should have quality, affordable health care in America.”

AAOS Now

Published 2/1/2008

Where do they stand on health care?

By Annie Hayashi, Jennie McKee, Peter Pollack, and Carolyn Rogers

In our final report on presidential candidates and their stances on healthcare issues, AAOS Now examines the proposals put forth by Sen. Hillary Clinton, D-N.Y.; Republican attorney Rudolph W. (Rudy) Giuliani; Sen. Barack Obama, D-Ill., and former Gov. Mitt Romney, R-Mass.

Information in this article is based on public documents and records; AAOS Now also contacted the candidates’ campaign offices, but was not always successful in obtaining replies to our inquiries.

Sen. Hillary Clinton: universal health care with a choice
In 1993, as First Lady, Hillary Clinton made her first attempt to reform the healthcare system. But the proposed healthcare reform package failed to gain approval by the U.S. Congress.

Hillary Clinton

As a Democratic presidential candidate, Sen. Clinton has developed a new healthcare plan—the American Health Choices Plan, which she described during a speech at Broadlawns Medical Center in Des Moines, Iowa, on September 17, 2007.

“The first rule of medicine is do no harm,” said Sen. Clinton. “And we will do no harm to the parts of our [healthcare] system that are working. Instead, we will build on them. That means not just expanding coverage, but also cutting costs and improving quality, so that we will have health care for all, and better health care for all. We need to address the concerns of those who have insurance, as well as those who do not.”

Sen. Clinton describes her American Health Choices Plan as a “public-private partnership” wherein those with private insurance would be able to keep their insurance, if they are satisfied with it. They would also, she says, be able to continue being treated by the doctors of their choice. Those who don’t have health insurance, or are unhappy with the coverage they have, would choose from the variety of private plans available to members of the U.S. Congress.

Sen. Clinton has proposed a seven-step strategy to lower the cost of health care, beginning with a national prevention initiative to reduce the incidence of diseases such as diabetes and cancer. She also proposes instituting a “paperless” health information technology system; ending insurance discrimination to help reduce administrative costs; creating an independent “Best Practices” institute to empower consumers, providers, and health plans to make the right care choices; and transforming the care of today’s chronically ill population to improve outcomes and decrease costs.

In addition, Sen. Clinton would implement several initiatives to constrain excess prescription drug and managed care expenditures and put in place “common-sense medical malpractice reforms,” along the lines of the National Medical Error Disclosure and Compensation (MEDiC) Act, which she introduced in Congress.

Sen. Clinton is quick to deny assertions by her Republican opponents that her healthcare plan would equate to government-run health care.

“My plan does not create a single new government department, agency, or bureaucracy. It is not a government takeover of health care. It is a public-private partnership that provides more choices,” she said.

Rudy Giuliani: Market forces can solve healthcare woes
Market forces can be used to keep healthcare prices down and make care accessible to all Americans, according to Republican presidential candidate Rudy Giuliani.

The former New York City mayor strongly opposes the concept of government-guaranteed universal healthcare coverage. At a forum at the Drake University campus in Des Moines, Iowa, Mr. Giuliani took aim at fellow presidential candidates who are proposing universal healthcare plans.

“[Universal coverage] is a nice promise to make, but you’ll be misleading people,” he said. “We will be leading them into a deteriorated healthcare system.”

Rudy Giuliani

Mr. Giuliani cited the falling prices of electronic goods such as televisions and cell phones as examples. “You’ve got to get those forces operating in our healthcare economy or it’s doomed.”

To make insurance more affordable, Mr. Giuliani supports an income exclusion of up to $15,000 for those without access to employer coverage. Other proposals include expanding access to Health Savings Accounts and offering a Health Insurance Credit for low-income Americans that can be coupled with other revenue sources such as Medicaid and employer contributions.

“Defensive medicine is a tremendous burden on our nation, with liability insurance in some states costing over $200,000 for obstetrician-gynecologists,” Mr. Giuliani states on his campaign Web site. “Ending frivolous lawsuits without limiting compensation for real economic loss is key to comprehensive health care reform.”

Mr. Giuliani would also offer states block grants to promote innovation, reduce costs, enroll eligible uninsured, and solve adverse selection issues.

“States regulations must not deny access to affordable coverage,” he said. “Currently more than 1,900 state mandates limit coverage options, and increase costs by 20 percent to 45 percent. If a state’s mandates prevent affordable healthcare coverage, citizens should be allowed to purchase coverage through interstate markets.”

Mr. Giuliani also targets the U.S. Food and Drug Administration’s (FDA) drug evaluation process for reform.

“After 1994,” she said, “when people asked me if I was going to give up on healthcare reform, I always had the same answer: Why would I give up on America and the American people? For so many years, I have listened to their stories. I carry these stories with me every day. I believe every man, woman, and child should have quality, affordable health care in America.”
Mr. Giuliani believes that increasing competition can reduce healthcare costs and improve the quality of care. “More people would be able to buy health insurance if the price dropped to $3,000 or less a year and tax incentives were offered to bridge the gap,” he said. “We’ve got to get a gigantic, complex market going that will drive the price down.”
Sen. Obama’s health plan comprises several different healthcare programs, including the existing private health insurance system and Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP). He advocates expanding eligibility for Medicaid and requiring healthcare coverage for all children.Uninsured Americans may choose between a “public plan” and a “National Health Insurance Exchange.”
Mr. Romney describes his approach to health care as a “free market, federalist approach.” During remarks made to the Florida Medical Association, Romney called the growth in healthcare spending in the United States “unthinkable.” He supports medical liability reform as one solution for controlling that growth and proposes the institution of caps on noneconomic and punitive damage awards to bring an end to the practice of defensive medicine and the elimination of frivolous lawsuits.

“The current FDA process is so regulated that a new drug takes 12 to15 years to get to the market,” Mr. Giuliani said. He wants to bring greater accountability and efficiency to the process to ensure that government regulation does not delay new cures or needlessly cost lives.

“Health insurance must be redefined to cover wellness in addition to sickness,” Mr. Giuliani added. His healthcare plan includes new initiatives to promote healthy lifestyles and wellness programs, and ties Medicaid payments to a state’s success in promoting preventive care and tracking obesity for children.

Barack Obama offers private and public programs
“Do we have the political will and the sense of urgency to actually get it done?” asked Sen. Barack Obama at a Democratic healthcare forum shortly after declaring his candidacy early last year. “I want to be held accountable for getting it done. I will judge my first term as president based on whether we have delivered the kind of health care that every American deserves and that our system can afford.”

Sen. Obama has proposed a plan for “universal health care” for every American; his opponents, however, say that because his plan is not mandatory, it cannot qualify as “universal.”

Barack Obama

The public program features guaranteed eligibility, comprehensive benefits similar to those in the Federal Employee Health Benefits Program, and portability that will allow participants to change jobs without jeopardizing their insurance coverage. It would be available for individuals and families who do not qualify for Medicaid or SCHIP.

The National Health Insurance Exchange (NHIE) will assist individuals who want to purchase a private insurance plan. It will also serve as a “watchdog group” to “help reform the private insurance market.” Participants would receive federal subsidies to enable them to purchase coverage.

By requiring insurance companies to follow certain standards and rules, Sen. Obama believes each individual will receive a policy that is fair and affordable with stable premiums that will not be affected by an individual’s health status.

Employers who meet certain revenue thresholds and are not currently offering healthcare coverage for their employees will be required to contribute a “percentage of payroll” toward the cost of the national plan. All of the plans offered through the NHIE must be as comprehensive as the public plan and meet the same standards for quality and efficiency.

Sen. Obama proposes technology and competition as two ways to substantially lower costs in the healthcare system. He would invest $10 billion over the next 5 years to create a “standards-based electronic health information system” that includes medical records. He assures the American public that patient privacy will be protected.

Increased competition between insurance carriers and drug manufacturers could also produce tremendous cost savings, according to Sen. Obama. He believes that his NHIE will increase competition between insurers, and he proposes to lower prescription drug costs by allowing Americans to buy their medications from other developed countries and repealing the ban on the Federal government from negotiating directly with drug companies.

Sen. Obama states that he will strengthen antitrust laws to prevent insurance companies from overcharging physicians for their malpractice insurance. According to his campaign, he will “promote new models for addressing errors that improve patient safety, strengthen the doctor-patient relationship and reduce the need for malpractice suits.”

Mitt Romney
While Mitt Romney (R) was serving as the governor of Massachusetts (2003 to 2007), the state legislature passed a law requiring all residents to obtain health care coverage. Residents who are unable to obtain or afford insurance through other means are provided the opportunity to purchase from a range of inexpensive policies subsidized by the state.

As president, Mr. Romney would similarly support redirecting money currently spent providing care to the needy in emergency departments to help the uninsured purchase insurance through private providers. He would also fix the tax code to level the playing field by making all healthcare expenses tax deductible and eliminating the special treatment afforded to employer-sponsored programs.

Mitt Romney

Although Mr. Romney has not issued an opinion directly addressing the flawed Medicare Sustainable Growth Rate formula for physician reimbursement, he does promote giving the states flexibility in spending Medicaid dollars in whatever way they think is most effective and efficient.

During the Oct. 9, 2007, Republican debate, he stated, “Instead of having the federal government give you government insurance, Medicare, and federal employee insurance, let’s have private insurance.”

Mr. Romney also argues that states need to take the lead in reforming health care and addressing rising costs. He would support expanding and deregulating the private health insurance market, and would encourage states to eliminate insurance regulations that he says drive up costs and push providers out of the market.

For more information

Sen. Hillary Clinton: http://www.hillaryclinton.com/

Mr. Rudy Giuliani: http://www.joinrudy2008.com

Sen. Barack Obama: http://www.barackobama.com/

Mr. Mitt Romney: http://www.mittromney.com