Somebody pointed me to this useful site recently.  It compares Obama and McCain's health care reform proposals side-by-side.

I think this description hits the main points of the proposals on the head.

Here are the things all voters should know:

> Remove the favorable tax treatment of employer-sponsored insurance and
> provide a tax credit to all individuals and families to increase
> incentives for insurance coverage...
>
> Reform the tax code to eliminate the exclusion of the value of health
> insurance plans offered by employers from workers’ taxable income....
>
> Provide a refundable tax credit of up to $2,500 (individuals) and $5,000
> (families) to all individuals and families for the purchase of
> insurance.

What does this really do?  Right now, if you get insurance through your job, you don't pay income tax on the value of the insurance.  The McCain proposal would change that.  If your employer gives you health insurance, its value would be taxable income.  You could claim a tax credit of $2500 per person or $5000 per family for your health insurance, whether it came from your employer or you bought it on your own.

Now, last I heard, the average health care spending of somebody with private insurance was around $4000.  Children are about $1100.  So... a single person would not have a tax credit anywhere near the cost of their health plan, and a family would have the same problem - but worse if it was a married couple.

With the tax-protected status of health insurance removed, employers would have no incentive to pay their employees with health insurance.  Most employers would be just as happy to get out of the insurance game, and under McCain's plan I expect they would drop employees - gradually, but it would dismantle employer-based coverage.

So, for poor families, does McCain have a way to help them buy health insurance?

> Work with states to create a federally-supported Guaranteed Access
> Plan for people who are denied coverage due to pre-existing
> conditions. Premiums in the plan would be limited and financial assistance
> given to those below a certain income level.

Oh.  So if you're healthy and poor, you're screwed.  And if you're middle-class and healthy, you're screwed.  Got it.

By the way, estimates of insurance spending for low-income adults and children indicate that health spending would be lower if everybody were enrolled in Medicaid instead of private insurance.  Note that a key piece of Obama's health plan is an expansion of Medicaid and the State Children's Health Insurance Program...

Sarah Palin?  Seriously?  That's the best McCain could come up with? 

The best critique I've read so far is from Robert Elisberg.
 

Senator Clinton:

Tonight you did an enormous disservice to the Democratic Party, to the causes you support, and to Americans across the nation.  Tonight you sowed the seeds of ongoing dissent, rather than offering your support to Senator Obama, who is now the nominee of the Democratic Party.

Your ongoing claim that you "won" popular vote, discounting the caucuses and counting Michigan (in which you were the only candidate on the ballot), and also counting Territories that will not vote in November - well, this is misleading and quite frankly pigheaded.

You clearly asked your supporters to continue to fight against a process with rules YOU AGREED TO month and years ago.

Your actions tonight were unbecoming a candidate.  Senator Obama treated you with far more kindness than he should in his speech. 

I personally, as a person who supports your causes and shares your concerns, ask you to stop.  It is time for unity, not ongoing battles based on faulty math and an unwillingness to follow rules.  Your campaign at this point has become an embarrassment.

[sent to her campaign, via her website]

It looks like I'll be a guest on KQED's Forum radio show tomorrow morning (Friday).  The description of the show on their web page says:

CNA Strike
The California Nurses Association is set to strike at 10 Sutter Health hospitals in the Bay Area for the next 10 days. Host Dave Iverson talks with the parties about the issues that led to the impasse.
Host: Dave Iverson
Guests:

Jan Rodolfo, registered nurse and member of the California Nurses Association negotiating team

Joanne Spetz, health economist and adjunct professor at the School of Nursing at UCSF

Kevin McCormack, spokesman for the California Pacific Medical Center

I listened to Senator Obama's speech on YouTube earlier tonight, and read some of the coverage.  You know, the Race Speech.  It is refreshing, and important, to hear the controversial and divisive issues the Senator broached discussed.  He went beyond saying "I'm not racist," and instead tried to help Americans understand why many blacks feel disenfrancished, and why many whites do as well.  And then he asks us to move forward.

...and yet another reason I voted for him, and hope you do too.

I'm going to broaden my usual writing to touch on a public issue that finally received some public attention.  Some of you might have heard about the article in the Journal of the American Medical Association about community health centers having a hard time recruiting physicians.  There was a good story about it on NPR on March 1.  I want to put the debate in context.

The Bush Administration's response to rising numbers of Americans without health insurance has been an unprecedented expansion of Community Health Centers.  These centers provide low cost care and free care to all patients.  They help patients navigate public insurance programs, such as Medicaid, and they offer a wide range of programs.  The best centers have primary care, maternity, pediatric, chronic illness clinics, and good relationships with hospitals.  This, in general, is a good program.  We can debate whether it's enough to address the problem of health insurance another time.

What the JAMA article reported is that these centers, which have expanded to care for an additional 6.1 million patients, are having a hard time finding physicians to take care of those patients.  The bricks and mortar are nice, but you need doctors, nurse practitioners, and nurse midwives to do the work.  The economics of supply and demand would tell us that the rising demand for these care providers should raise wages, and in the long term more people will want to enter these specialties... so over the course of a few years, the "shortage" will remedy itself.  This theory tells policymakers that they needn't worry about the shortage reported in JAMA, because it will take care of itself.

There are a few reasons the classic supply-demand mechanism won't work:

1. Community Health Centers operate on very tight budgets and can't afford to raise physician/NP/NM salaries much

2. Even if salaries rise and young doctors want to enter the primary care specialties, their ability to do so is constrained by the number of residency slots available.

3. Even if demand for primary care residency slots rises, medical schools (and other hospitals) that operate residency programs might not expand the primary care programs.  Quite frankly, med schools make a ton of money from cardiac care services and other specialities.  Reimbursements for these types of care are good, specialty services are attractive to patients and bring them in.  Primary care is not profitable for medical schools... not that med schools are seeking a profit, but they are seeking reputation, enough money to invest in future expansion/technology, and so forth.  If a med school can bring in good revenue from Medicare patients with an expanded cardiology program (and thus expanded cardiology residency), and lose money from uninsured and Medicaid patients with a primary care residency program at the public hospital, which do you think is going to get expanded?

On this last point, this is where the government has played a role.  Decades ago, the government established Title VII programs in the Department of Health and Human Services.  These programs, now operated by the Bureau of Health Professions, provide funds to medical schools to support primary medical education.  This grant funding provides an incentive, and resources, to medical schools to offer and expand their primary medical education programs.  But, last year's federal budget reduced funds for this program by 50%.  The new President's Budget for 2007 nearly eliminates this program.  The http://www.whitehouse.gov/omb/budget/fy2007/hhs.html say "...the programs were created 40 years ago in response to an anticipated national shortage of physicians that does not exist today. An assessment of the program found it was ineffective. No comprehensive evaluations link Health Professions grants to changes in supply, distribution, or minority representation of physicians and other health professionals."

There are a few things to know about this budget statement:

1. The White House is now heavily influenced by economists who believe the supply-demand mechanism (often called "the market") will remedy the physician shortage.  These economists, such as Mark McClellan and Joe Newhouse, are extremely bright people who I respect a lot, but I think they are wrong in this case.  Note that Joe was one of Mark's mentors when Mark was doing a MD-PhD with Harvard-MIT.  These are smart people, some of the best economists and researchers in the world... but that doesn't mean they are always right about policy.

2. There is not an overall shortage of physicians today, especially in places like Boston and San Francisco where there are a lot of medical education programs and doctors like to live there.  But let's talk about Coalinga, California.  They have a tiny hospital that had to shut down its maternity services because it couldn't afford to keep an obstetrician in town.  We can talk about inner-city hospitals that have a hard time recruiting physicians.  There are regional shortages, which are closely tied to how rich the residents are, how many amenities the community offers (city-trained doctors get used to city services), and things that these communities can't change easily. 

3. The assessment of the program didn't examine the outcomes the program was intended to achieve.  The management of the program has been a problem, and the Bureau of Health Professions never did good evaluations of whether their programs were meeting community needs.  These are failings of the management of Title VII, but not necessarily that Title VII isn't meeting its goals.  We're even less likely to find out whether Title VII has been successful because the current budget eliminated the National Center for Health Workforce Data and Analysis.  

For most Americans, who live in suburbs, have jobs, and have health insurance, these issues are not very interesting.  But the disconnect within federal policy, and the effects of this disconnect on the poorest Americans - many of whom work, go to church, and are trying to make ends meet - are severe.