Neil Chesanow
And Then There Were Three
On May 3, New York real estate tycoon Donald J. Trump trounced his chief rival, Texas Senator Ted Cruz, to win Indiana's primary, forcing Cruz to quit the race and positioning Trump to easily accumulate the 1237 delegates needed to avert a contested Republican nominating convention in Cleveland in July.[1]
Republican National Chairman Reince Priebus declared Trump the "presumptive nominee."[1] The next day, Ohio governor John Kasich, who had won only his home state, also suspended his campaign.[2]
On the Democratic side, Vermont Senator Bernie Sanders scored an upset victory—winning 52.7% of the vote among Indiana Democrats—over former Secretary of State Hillary Clinton.[3] The following week, Sanders captured the West Virginia primary. Although he vows to remain in the race until the Democratic nominating convention, to be held in Philadelphia in July, it is mathematically impossible for him to reach the number of regular delegates necessary to win the nomination using pledged delegates alone.[4]
Sanders would instead have to win over superdelegates—party leaders and elites who can back the candidate of their choice.[4] However, to date, Clinton has won 520 superdelegates to Sanders's 39, making this route to the nomination unlikely.
But by remaining in the race, Sanders could still influence the Democratic party platform, nudging it to the left in Philadelphia.[5] His unexpected success, particularly with younger Democratic primary voters, has already prompted Clinton to add a public option to her proposals for reforming the nation's healthcare system in the hope of winning their support in the general election.
What the three candidates propose to reform the nation's healthcare system is a study in contrasts. Clinton seeks to build on the successes of the Affordable Care Act (ACA); she proposes incremental change.[6] Sanders seeks to replace the ACA with single-payer, Medicare-for-all coverage.[7] Trump also proposes revolutionary change, starting with repeal of the ACA, but details on what he would replace it with have not yet been revealed.[8]
How realistic are their proposals? If enacted, what would they mean for you and your patients? Let's take a look.
Hillary Clinton's Healthcare Proposals
Of the three candidates' proposals, Clinton's are the most factually detailed.[6] For supporters of Bernie Sanders, however, this is a criticism, not a compliment. Her proposals, in their view, fail to address the nation's healthcare problems, starting with the 33 million people—10.4% of the population—who remain uninsured.[9]
"She's really proposing more or less a continuation of current policies, with very minor tweaks as far as things that would really affect doctors," contends internist David Himmelstein, MD, professor at the CUNY School of Public Health at Hunter College in New York, lecturer at Harvard Medical School, and cofounder of Physicians for a National Health Program. "What you see is what you get."
"What you get" is, in the view of many doctors and patients, a significant improvement over health policy before the ACA was enacted, but it has left many others, regardless of their political orientation, deeply disappointed.
Internist Marc K. Siegel, professor of medicine at New York University School of Medicine and a Fox News medical correspondent, is one of them. Dr Siegel describes himself as "a practicing physician who has studied and been victimized by the damaging effects of Obamacare." On the right-wing FoxNews.com, he writes, "I am on the lookout for any plan that aims to undo the worst of Obamacare: spiraling premiums, limited access to providers, high deductibles that hamstring poor and middle-class patients, and heavy federal subsidies and related tax hikes."[10]
Such criticisms are echoed in many liberal media outlets as well. A New York Times op-ed, "Sorry, We Don't Take Obamacare," notes that "some early studies of the impact of the Affordable Care Act plans are proving patients' grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients' home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy."[11]
Affordable Care Act
Clinton is the only candidate who supports the ACA. As her website declares, "Hillary will defend the Affordable Care Act and build on it to slow the growth of out-of-pocket costs."[6]
Healthcare Costs
Clinton says she would lower out-of-pocket costs like copays and deductibles—which, in employer-sponsored health plans, rose from $1240 in 2002 to about $2500 in 2013.[6] One way she would do this is by offering a tax credit of up to $5000 per family that buys its health insurance on an ACA exchange, to offset out-of-pocket and premium costs above 5% of their income.
She would require all health plans, including employer-provided plans, to give individuals three sick visits per year without needing to meet the deductible first.[6] According to a study by the Commonwealth Fund, 31 million Americans with health coverage were nevertheless underinsured in 2014, with high deductibles or out-of-pocket costs relative to their income.[12] As a result, many skip needed care. A tax credit, it is hoped, would help address this gap.
Clinton would enhance the tax credits for health insurance premiums currently available through the ACA exchanges.[6] Families purchasing insurance on an exchange would not spend more than 8.5% of their income for premiums—less than under current law.
She would eliminate a glitch in the ACA that makes whole families ineligible for premium subsidies if even one member of the family is eligible for employer-paid insurance, even if that plan is too expensive to cover everyone in the family.[6]
Clinton would increase price transparency so that people understand how much their healthcare costs and can more easily comparison-shop for the best deals.[6]
She would protect consumers against surprise medical bills.[6] For example, patients may use a health plan's in-network hospital, thinking that they only owe the deductible specified in their policies, yet end up receiving unexpected multi-thousand-dollar bills from anesthesiologists, surgeons, radiologists, emergency physicians, and other doctors who, unbeknownst to them, were not in the network. Clinton would absolve consumers from having to pay those extra charges.
She would enforce antitrust laws and investigate mergers, consolidations, and business practices of providers and insurers that could harm consumers.[6]
She would strengthen state authority to block excessive insurer rate increases.[6]
Drug Prices
Reducing the cost of prescription drugs—for which spending leaped from 2.5% in 2013 to 12.6% in 2014—is a Clinton priority.[6] She would require insurers to cap out-of-pocket drug spending for health plan members at $250 per month, fully fund the US Food and Drug Administration's (FDA's) Office of Generic Drugs to speed low-cost generic drug approvals, and reduce the amount of time that brand-name biologic drug makers are protected from price-cutting competition from 12 to 7 years.[6,13]
All three primary candidates have proposed allowing Americans to import less-expensive medications from abroad, provided that safety standards are equivalent to those here.[6-8]
This is easier said than done. "How is the FDA to monitor all the possible international vendors that want to sell Americans drugs?" wonders economist Merrill Matthews, resident scholar at the Institute for Policy Innovation, a nonpartisan think tank.[14] "There are huge profits to be made—that are already being made—selling US consumers fake, outdated, diluted, and compromised drugs at a fraction of the US pharmacy price. Both organized crime and terrorists have become involved, and they would love easier access to the US market."
Importation of lower-priced drugs is not the only market intervention that Clinton has proposed. She would eliminate tax breaks for drug companies whose advertising is aimed at consumers.[6,12] And she would put pressure on pharmaceutical companies to spend more of their revenue on research and development.
All three primary candidates would rescind the 2003 federal law that forbids the federal government from negotiating Medicare drug prices directly with drug companies to get better deals for Medicare beneficiaries.[6-8] For Clinton and Sanders this is no surprise; repealing the law has long been a Democratic goal. For Trump, it subverts the small-government, free-market ideals of the GOP.
Clinton would require pharmaceutical manufacturers to provide rebates to low-income Medicare enrollees equal to those offered under the Medicaid program.[6]
She would move the healthcare system away from fee-for-service toward bundled payments to reduce doctors' incentives to order excessive tests and procedures, a shift that is already underway.[6] The proposed rule on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), announced on April 27, would incentivize doctors to participate in alternative payment models—including bundled payments and accountable care organizations—which are intended to reimburse doctors for quality of performance, not quantity of procedures.[15]
Clinton would broaden the use of telehealth, particularly in underserved rural areas.[6]
Medicare
Clinton opposes any plan to privatize Medicare, although Trump, paradoxically for a conservative, would leave the Medicare program untouched.[6,8] It's paradoxical because, with large numbers of people becoming eligible for Medicare with each passing year, the program is a prime reason why healthcare costs are rising unsustainably. Privatizing Medicare by block-granting it to the states would help control these costs, conservative leaders maintain.[15-17] Leaving the program intact, to their way of thinking, would be fiscally irresponsible, something that only a liberal would be expected to advocate.
Medicaid
Clinton supports state expansion of Medicaid under the ACA.[6] To make this palatable to the 16 holdout states—all under the control of anti-ACA Republican governors or legislators—the federal government would pick up 100% of the expansion's cost for the first 3 years of implementation.[18] The government's current offer to fund the full Medicaid expansion cost for 3 years ends this year.
"Her hope is that the prospect of more free money will goad these states to climb down from their ideological resistance, even if the prospect of providing decent health coverage to hundreds of thousands of their lowest-income residents hasn't done the trick," explains Los Angeles Times business columnist Michael Hiltzik.[18]
As many as 16 million people—about half of those who remain uninsured even after the implementation of the ACA—are eligible for virtually free Medicaid or ACA exchange coverage for as little as $100 per month.[6] Yet they are not enrolled, presumably due to lack of awareness or inability to navigate the enrollment process. Clinton would invest $500 million per year in navigators, advertising, and other outreach efforts to spread awareness and make enrollment easier.
The Public Option
The enthusiasm of Millennials and many other Democrats for Sanders's Medicare-for-all plan prompted Clinton to revive support among "interested governors" for a "public option," which she had proposed in 2008 when competing against Obama in the Democratic primaries.[6,9,18] This would bring competition to the commercial insurance industry via a federal government–run alternative that would let Americans between 55 and 65 years of age buy into the Medicare system as an alternative to purchasing commercial insurance.
Clinton would not try to push a public option through Congress (as Sanders would attempt to do with his single-payer plan). This would be futile as the Senate and House are currently constituted, reports Politico, a website for Washington insiders. Instead, Clinton "will work with governors using existing flexibility under Obamacare 'to empower states to establish a public option choice.'"[19]
"Doctors and hospitals would be very likely to oppose the idea, because they prefer the higher reimbursement rates of private insurance companies," the New York Times notes in a May 12 editorial.[9] "Insurers would also fight it because they don't want to compete with the government program for customers."
Both advocates and opponents view a public option as a step toward universal coverage.[19-21] If it proved a popular alternative to costlier commercial insurance, there would be a mandate to expand eligibility; expanded eligibility moves us closer to Medicare-for-all, which would vastly increase healthcare costs, conservatives fear.
Women's Health
Finally, Clinton would protect women's access to reproductive health, including contraception and safe, legal abortion.[6]
Bernie Sanders's Healthcare Proposals
Bernie Sanders's proposals for reforming healthcare are presented in broader brushstrokes than Clinton's are, and they are lighter on details.[7] On Sanders's website, more space is devoted to how he intends to fund his single-payer plan than on the plan itself, although these details, too, are sketchy.
To be fair, Clinton's proposals, as a continuation and tweaking of existing, complex policies under the ACA, intrinsically lend themselves to more detail, whereas the appeal of a single-payer plan is its sweeping simplicity.
"Healthcare must be recognized as a right, not a privilege," Sanders has declared.[7] "Every man, woman and child in our country should be able to access the healthcare they need regardless of their income. The only long-term solution to America's healthcare crisis is a single-payer national healthcare program."
How would Sanders achieve this vision?
Affordable Care Act
The Medicare-for-all system that Sanders envisions would replace the ACA. It would provide all Americans with comprehensive health services, including "inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing, and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments."[7]
In addition, "patients will be able to choose a healthcare provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs."[7]
Private insurance would only be available to provide supplemental coverage.
Healthcare Costs
The federal government would set a fee schedule for all providers and hospitals, as the Centers for Medicare & Medicaid Services currently does for Medicare beneficiaries.[7] This would mean "no more copays, no more deductibles and no more fighting with insurance companies when [patients] fail to pay for charges."
Drug Prices
Sanders, like Clinton and Trump, would require the federal government to negotiate drug prices for Medicare.[6-8]
In the Sanders plan, generic drug makers would pay a rebate to Medicaid if their prices increase more than the rate of inflation.[7]
Medicare prescription discounts for low-income seniors would be restored.[7]
Brand-name drug makers would be prohibited from paying generic drug makers from delaying generic drugs from coming to market.[7]
Consumers, pharmacies, and wholesalers would be allowed to import drugs from licensed Canadian pharmacies.[7] A version of this proposal is also embraced by Clinton and Trump.[6,8]
As part of price transparency, Sanders would require pharmaceutical manufacturers to disclose the prices they charge for drugs overseas.[7]
Medicare
Sanders would expand the Medicare program to cover every American under a single-payer system.[7]
He would close the Medicare prescription drug coverage gap—the "donut hole"—by 2017, 3 years earlier than is scheduled under current law.[7]
Medicaid
Until a universal health plan is passed, Sanders would expand and improve the program for low-income families.[7]
Women's Health
Sanders would increase funding for Planned Parenthood; the Title X program, the only federal grant program providing low-income families and uninsured people with comprehensive family planning and related preventive health services at reduced or no cost; and access to birth control.[7,22,23]
Sanders, like Clinton, would ensure the availability of safe and legal abortions.[6,7]
How Would Doctors Be Affected?
Many doctors feel that Medicare reimbursements are already insufficient. How would their earnings be affected if all of their reimbursements came from Medicare?
They wouldn't be affected much at all, contends Dr Himmelstein, who has coauthored studies on the high administrative costs of the US healthcare system. It is the administrative costs of running a medical practice—in particular, dealing with insurers—that eat into doctors' earnings, he says. Reduce or eliminate them, and Medicare reimbursements would be much less of a cause for complaint.
"Doctors' fees might go down a little bit," Dr Himmelstein concedes, "but you'd be paying much less for your office overhead. The average doctor is paying something like 30% of his or her gross income for billing and administrative costs. If you cut that very substantially, you don't take an income cut if you have slightly lower fees. The Sanders program will actually get rid of a lot of those overhead costs, as Canadian doctors have experienced, and their take-home pay will remain roughly where it is today."
But many critics of Sanders' plan—liberal as well as conservative—assert that the savings from billing and administrative costs under a single-payer plan have been grossly overestimated.
"The cost question is particularly knotty, as Sanders assumes a 20 percent cut in [healthcare] spending averaged over 10 years, even as roughly 30 million currently uninsured people would gain coverage," Henry J. Aaron, a senior fellow in economic studies at the liberal-leaning Brookings Institution, points out in Newsweek.[24] "Those savings, even if actually realized, would start slowly, which means cuts of 30 percent or more by Year 10. Where would they come from? Savings from reduced red-tape associated with individual insurance would cover a small fraction of this target. The major source would have to be fewer services or reduced prices."
"Who would determine which of the services physicians regard as desirable—and patients have come to expect—are no longer needed?" Aaron wonders.[24] "How would those be achieved without massive bankruptcies among hospitals, which would follow such spending cuts? What would be the reaction to the prospect of drastic cuts in salaries of healthcare personnel—would we have a shortage of doctors and nurses? Would patients tolerate a reduction in services?"
Is Cutting Administrative Costs Enough?
Progressive columnist Ezra Klein, editor-in-chief of the political website Vox, has reached the same conclusion.
"The real way single-payer systems save money isn't through cutting administrative costs," Klein observes.[25] "It's through cutting reimbursements to doctors, hospitals, drug companies, and device companies. And Sanders gestures toward this truth in his plan, saying that 'the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively.'
"But to get those savings, the government needs to be willing to say no when doctors, hospitals, drug companies, and device companies refuse to meet their prices, and that means the government needs to be willing to say no to people who want those treatments," Klein continues.[25] "If the government can't do that—if Sanders is going to stick to the spirit of 'no more fighting with insurance companies when they fail to pay for charges'—then he won't be able to control costs."
Health economics expert Kenneth Thorpe of Emory University, who was hired by the legislature of Sanders's home state, Vermont, to develop a single-payer proposal, and which the legislature subsequently decided that the state couldn't afford, has run Sanders's numbers and concluded that his campaign has underestimated the cost of his Medicare-for-all plan by about $1 trillion annually.[26] Covering that extra spending would require an income-based tax of a whopping 20%, not the already steep 8.4% proposed by Sanders, in addition to the taxes Americans already pay.
"Of course," notes Washington Post economics columnist Paul Samuelson, a conservative critic of the single-payer plan, "Sanders could control costs with cuts in reimbursement rates to doctors, hospitals and other providers.[27] (If government pays for most health care, it presumably would—as with Medicare—set reimbursements.) But this might trigger protests that patients would suffer. With time, stingy reimbursement might also lead to longer wait times as shortages of doctors, nurses and hospitals emerged."
On May 9, the nonpartisan Tax Policy Center issued a detailed analysis of Sanders's healthcare proposals, including his single-payer system, and found them profoundly flawed.[28,29] Sanders's assurance that he has "a plan to pay for every spending program he introduced to date"—not just single-payer but free college tuition and a range of new benefits for the poor—is extravagantly wrong, the center's analysts concluded. Even with the large tax increases that Sanders has proposed, his collective plans would add $21 trillion to the national debt over a decade, more than the roughly $19 trillion already owed.
Sanders's single-payer plan alone would cost $32 trillion over 10 years, more than twice the revenues that Sanders's taxes would raise, the analysts determined.[28] In response, Sanders countered that other countries have functioning single-payer systems.[29] True—but they are not as generous as Sanders's plan, in which virtually everything is covered. Making his system less expensive, the analysts concluded, would require deep cuts to physician and hospital reimbursements, which in turn would cause "supply constraints"; a shortage of providers willing to meet the demand for health services would make it harder to access care.
Donald Trump's Healthcare Proposals
Donald Trump's healthcare proposals are far less detailed than those of Hillary Clinton, and according to numerous GOP health policy experts, they are philosophically inconsistent. For example, Robert Laszewski, president of Health Policy and Strategy Associates and a former insurance company executive, calls them "a jumbled hodgepodge of old Republican ideas, randomly selected, that don't fit together."[30]
"Donald Trump has released his health care plan after being pressured into doing so," economist Merrill Matthews noted in Forbes in March.[14] "He should have taken a little more time. Though six of his seven points—they aren't developed enough to be called proposals—are standard Republican fare, they are too vague and superficial to determine what Trumpcare would be like."
Here, in any event, is what Trump is advocating.
Affordable Care Act
Trump calls for "a full repeal of Obamacare." But he still says that "everybody's got to be covered."[8,31] Assuming that he truly means "everybody," between 2010, when the ACA was passed, and 2014, 10 million uninsured Americans gained coverage. If the ACA were repealed, they would lose it.[9] In addition, 33 million Americans continue to lack health insurance coverage.[9]
If "repeal and replace" would help all of those people keep or gain coverage, the question arises: Replace with what? Trump has not yet supplied that information.
To be fair, the Republican-controlled House of Representatives has tried to repeal the ACA over 60 times, Matthews points out, and they have yet to propose a replacement plan either.
"One of the most frequently asked questions I get out there, if I'm giving speeches, is, 'What's the Republican plan?'" Matthews told Medscape. "You can't really give an answer to that. There are several potential elements for a Republican plan. But the leadership has never rallied around four, five, or six points that they could say are the basic elements of our plan."
Healthcare Costs
Trump would leave the Medicare program untouched.[8]
He says he would let the cost of insurance premiums be deducted from federal income tax so that "no one slips through the cracks simply because they cannot afford insurance."[8]
Trump would let individuals use health savings accounts (HSAs) to pay for out-of-pocket expenses,[8] although "HSAs have been in law since 2003 and in practice maybe a year after that," American Enterprise Institute (AEI) economist and health policy expert Tom Miller told Medscape. "There's not really any proposal there, other than recognizing what already exists and saying, 'Yeah, I think it's a good idea.' It shows a lack of familiarity with well-established health policy."
Trump would, as his website says, "modify existing law that inhibits the sale of health insurance across state lines.[8] As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up."
But it's not so simple, Matthews points out.
"Health insurance is tied to a local network of providers—doctors, hospitals, clinics, and sometimes pharmacies," he observes. "If you're in one state, find an affordable policy in a state across the country, and want to buy that policy, even if you could, how does the insurance company get its contracted provider network in the other state back to the state you are in?"
"If you're in New York and are buying a policy from a state that's much less expensive, your premiums would be higher anyway because of the higher cost of living and other costs," Matthews elaborates. For example, lower premiums in a state like Wyoming would also reflect state-mandated benefits and coverage, local competition, and provider treatment patterns that don't apply to New York.
However, the assumption that open borders would allow insurers in low-regulation, low-cost states to sell their less-expensive products in costlier high-regulation states at a competitive advantage over insurers already serving those markets is also questionable, Matthews maintains.[14] Since the passage of the ACA, which mandates what health insurance coverage must include, low-regulation, low-cost states are a thing of the past, he says, even if the problem of contracting with far-flung provider networks could somehow be overcome.
Drug Prices/Medicare
Trump says he would let Medicare negotiate with drug makers to lower drug prices.[8] In 2003, the pharmaceutical industry convinced Republican legislators to forbid Medicare from negotiating drug prices when Congress enacted the law creating Part D drug plans.[32,33] Changing the law is strongly opposed by drug makers and the GOP. Republican thought leaders support market competition to drive down drug prices and seek to shrink the role of government, not greatly expand it.
In addition, Trump would lower barriers to purchasing cheaper medications from other countries (proposed by Clinton and Sanders as well), drawing flak from the Right that he is not a true conservative, only masquerading as one.[8]
"Trump has deviated from most Republican orthodoxy on prescription drug pricing on both ends," AEI's Tom Miller observes, "first by directly taking a hands-on approach to suggest that the President be very active in directly negotiating the prices of brand-name drugs as a large purchaser to lower rates; and then by proposing the reimportation of drugs, which is not a new idea—but for a Republican presidential candidate to be aggressively embracing that, that's new."
Republicans are in favor of increased price transparency, one of the least controversial of Donald Trump's proposals.[8] One way to contain healthcare costs, GOP leaders maintain, is for consumers to be less insulated from the cost of their care and have "more skin in the game" (ie, pay more for their care out of pocket).[14] This would incentivize them to make cost-conscious decisions regarding their care, for which price transparency would be a necessary precondition.
Medicaid
In a move long advocated by conservatives but fiercely opposed on the Left, Trump proposes (as Ted Cruz did before him) to award federal funding to administer the Medicaid program via block grants to the states.[8]
"Nearly every state already offers benefits beyond what is required in the current Medicaid structure," Trump's website says.[8] "The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources."
This would cut federal funding for the Medicaid program by $913 billion over the next decade, according to the Patient Choice, Affordability, Responsibility, and Empowerment Act (the Patient CARE Act), introduced by Republicans in 2015 and awaiting a GOP president to sign it into law. This, GOP leaders maintain, would help stem the unsustainable rise in healthcare costs.[34]
"Block-granting Medicaid is a very common Republican proposal," counters Dr Himmelstein. "What it does is give states license to cut Medicaid, which I think has quite severe repercussions."
"Such a law would be bad news for beneficiaries and for providers, especially those that serve low-income communities, since under such financing terms few, if any, states could maintain existing coverage for affected populations," write Sara Rosenbaum and Timothy Westmoreland in the New England Journal of Medicine.[34] The reduced budgets "would force most states to put eligibility, benefit, and cost-sharing protections on the line as they attempted to cope with the brunt of future cost growth."
Women's Health
In the healthcare proposals posted on his website, Trump doesn't mention women's health. But he has gone on record elsewhere as saying that Planned Parenthood should be defunded.[35]
On abortion, Trump has changed his position so often that it's hard to know what he actually believes.[36] At various times, he has said that he is pro-choice and pro-life.[36] He recently said that women who have abortions should be punished; an hour later, his campaign issued a statement of clarification to the effect that doctors who perform abortions should be punished, not women who have abortions.[36] Most recently he has said that he "will change the law through his judicial appointments and allow the states to protect the unborn."[36]
The Health Policy We Deserve?
According to health policy expert Tom Miller, none of the candidates' plans for reforming healthcare in America address the hard questions that would make true reform possible. He says some of those questions are[37]:
- Who gets to make the initial decisions in healthcare? Who controls the money up front and then attaches strings on how others might receive it?
- What do we want the healthcare system to do, and how do we measure its performance?
- How should we re-balance health spending commitments to match them better to the resources we have to meet them, along with other competing to needs and preferences?
- How far can, and should, we go in climbing the steepening slope toward near-universal coverage?
"Having worked with politicians on these things, especially on healthcare, for a long time, I can tell you that most of them—Republicans and Democrats alike—simply don't understand what they're doing," Merrill Matthews told Medscape.
"We get the health policy we want rather than the health policy we deserve," Miller reflects. "People would rather hear simple answers to the wrong questions and wonder why they get results they don't like. The candidates vary in the degree of engagement, sophistication, and interest in health policy issues. But even those who seem to be more engaged and interested are repeating a number of the wrong approaches that have helped make the situation worse rather than better."
"Whatever might be a better remedy does not appear to be on the horizon at the moment,” Miller concludes. "We are going to have to have some more negative experience before finding out that what we wish may not be possible. If we took more direct control of and engagement in some of these health policy decisions ourselves, we might end up with better results."