OncoLink Inside Politics: Campaign 2008 - A Summary of the Candidates’ Views on Domestic Healthcare Policy Issues

Nick Lukens, MSIV
University of Pennsylvania School of Medicine
Ultima Vez Modificado: 21 de noviembre del 2007

Health care is one of the key domestic policy issues for the 2008 presidential campaign, and both Democratic and Republican candidates are jockeying for position. Here’s a look at some of the major health care issues that are likely to have an impact on cancer patients and their care, and what stances the leading candidates have taken so far.

The Issues

• Universal Health Care: There are approximately 47 million individuals in the United States who do not have health insurance, according to the most recent Census Bureau statistics. One study found that 5% of all cancer patients are uninsured at their diagnosis, and that these patients have fewer encounters with their doctors than insured patients. Uninsured cancer patients have also been found to have higher mortality rates.

• Catastrophic coverage: Many patients who have insurance find out that aspects of their cancer care are not covered by their insurance. One out of every four cancer patients with insurance use up all or most of their life savings while treating their cancer because of the extraordinary costs. One study estimated that medical bills contribute to half of the 1.5 million personal bankruptcies filed in the United States each year. Three-quarters of these patients actually had health insurance.

• Fair terms for health insurance: Currently, patients with pre-existing medical conditions like cancer can be denied coverage, refused renewal of insurance, or charged higher premiums for insurance. Some patients face a “pre-existing condition exclusion period” when they sign up for a new insurance policy, which means that there is a waiting period during which the expenses of treating pre-existing conditions will not be covered. The wait can be up to one year for coverage provided by an employer, or longer if the plan is not group coverage.

• Coordinating care for chronic conditions: Many patients with cancer have other chronic medical conditions, and see multiple sets of health care providers, leading to duplicate tests, conflicting prescriptions, and lack of communication between providers. One potential solution endorsed by the American College of Physicians is the “Advanced Medical Home” model, which links patients with certain conditions to a personal physician who coordinates all of their care.

• Increased emphasis on Preventative Screenings: Most health-care dollars are currently spent on treating medical conditions once they are diagnosed, rather than on routine screening for cancer and other medical conditions.

• Support for patients, families and their caregivers: Taking care of loved ones with cancer or other chronic medical conditions places an untold burden on caregivers, and often these providers go without support themselves. Additionally, long-term survivors face a different set of problems, which are only beginning to be addressed.

• National Institutes of Health (NIH) Funding: Funding for research at the National Cancer Institute (part of the NIH) has been relatively flat since 2005. Scientists are concerned that promising lines of research will not be pursued due to a lack of adequate funding.

• Stem Cell Research: Restrictions on embryonic stem cell research threaten to hamper progress in the treatment of diseases where the goal is to create new functional tissue, more so than in the treatment of cancer, where the goal is to destroy malignant tissue. Nevertheless, stem cell research may lead to advancements in the treatment of certain types of cancer.

• Reducing Environmental Risk Factors: Certain types of cancer can be prevented through lifestyle changes, or making the environment in which people live and work safer. Smoking cessation programs and disclosure of potentially carcinogenic chemicals in consumer products are examples of steps that can be taken to reduce these risk factors.

The candidates have issued health care proposals that vary widely in terms of the degree of detail about proposed initiatives and funding. So far, the Democratic candidates have addressed these issues in greater detail than the Republicans. Here we outline how the leading contenders from each party stand on the health care policy issues mentioned above.

The Democratic Candidates

Hillary Clinton has put forward her “Health Choices Plan,” which details her proposal to expand health insurance coverage and make it more affordable. She also outlined her Plan to Fight Cancer at the LIVESTRONG Presidential Cancer Forum in Cedar Rapids, IA.

• While she avoids the term “universal” health coverage, her plan to broaden coverage, like Edwards’, places responsibility on businesses, individuals, and the government. Individuals will be required to purchase insurance, but can choose from their existing plan, the range of private plans available to members of Congress through the Federal Employee Health Benefit Program, or a public insurance option similar to Medicare. Large employers will be expected to provide health insurance, while small businesses will receive a tax credit to offer coverage. Like Edwards, her plan will also strengthen Medicaid and SCHIP, and will provide tax credits to individuals to make premiums affordable. Finally, she plans to limit premiums to a percentage of income.
• In terms of catastrophic coverage, Clinton states that “the plan ensures that job loss or family illnesses will never lead to loss of coverage or exorbitant costs,” but her campaign did not reply to several requests for details on how she will limit these expenses for individuals.
• Clinton proposes to end insurance discrimination by creating national guidelines stipulating that no individual may be denied coverage, refused renewal, or forced to pay excessive premiums. She also addresses the possibility that genetic tests may be used for discrimination, and says that “insurance companies would not be allowed to require genetic tests or consider the results of any test when determining eligibility for or cost of health insurance.”
• To help manage the care of the chronically ill, Hillary supports the establishment of “medical homes” to coordinate patient care.
• Like Edwards, Clinton’s plan would require insurance companies to cover preventive services proven to be effective. This would include increasing access to cancer screening, and following through on initiatives to prevent young adults from starting to smoke.
• In terms of research funding, Clinton proposes to “increase the NIH budget by 50% over 5 years and aim to double it over 10 years.” She also promises to “rescind the ban on ethical embryonic stem cell research.” Finally, she would like to maintain Medicare coverage of clinical trials, which allows many more Medicare patients with cancer to enroll in clinical trials.
• Hillary proposes enhanced support for cancer survivors, in the form of $25 million from the CDC for community-based support groups, and the establishment of a survivorship study to examine the long-term impact of cancer treatment, especially on young patients.

John Edwards has put forward a detailed proposal for revamping health care, including its cost ($90-120 billion a year) and ways to fund his proposals. He has also proposed a National Strategy on Cancer Survivorship.

• His plan for creating universal health coverage has several components, placing responsibility on businesses, the government, and individuals: businesses will be required to provide coverage for their employees; the government will provide tax credits for purchasing insurance, and expand Medicaid and SCHIP (insurance for children); and individuals will be required to purchase insurance. Edwards also plans to create regional “Health Care Markets” that will give individuals bargaining power to purchase insurance.
• In terms of catastrophic coverage, “Edwards has not proposed a catastrophic reinsurer,” according to a spokesperson for his campaign. “Just as it is today, the patient’s insurer will pay for all covered costs.”
• He plans to “ require insurers to keep plans open to everyone and charge fair premiums, regardless of preexisting conditions, medical history, age, job, and other characteristics.” When asked about how he plans to accomplish this, his campaign points to the fact that many states have “guaranteed issue,” which ensures that insurers cannot discriminate based on preexisting conditions, and “community rating,” which forces insurers to charge every policyholder similar prices . His campaign does not address the concern that such policies force insurance companies to raise premiums for everyone.
• His plan “will require insurance companies to offer a full range of preventive and early treatment services, including screening for cancer at little or no cost.”
• In order to streamline chronic care, Edwards supports the establishment of “medical homes,” where therapeutic and palliative care will be coordinated.
• To support caregivers, Edwards supports respite care services and wants to establish an Internet clearinghouse to give families more information about available services.
• Edwards proposes “substantial” increases in funding for the NIH, and also promises to lift restrictions on embryonic stem cell research.
• On the issue of environmental risk factors, Edwards supports smoking cessation programs and will “ strengthen the EPA and FDA's power to require testing and labeling of potentially toxic chemicals in foods and consumer products.”

Dennis Kucinich warrants mention because he is the only candidate to endorse a universal, single-payer, not-for-profit health care system based on Medicare.

Barack Obama has a plan to provide universal health coverage that echoes elements of Edwards’ and Clinton’s plans.

• Obama’s plan includes a business mandate, that all but the smallest businesses must provide coverage for their employees or help foot the bill. He plans to create a new public insurance plan (à la Clinton) for individuals who are not eligible for Medicare or Medicaid, and who cannot get insurance through work. He also plans to create a “National Health Insurance Exchange” (similar to Edwards), which would be a regulated market for competing private health insurance plans.
• Obama addresses catastrophic expenses as one of the factors driving up insurance premiums. He proposes to reimburse employer health plans for a portion of the catastrophic coverage, in exchange that these savings be used to reduce premiums for all employees.
• He takes a stance against insurance discrimination, saying that he will “ require insurance plans to accept all applicants and not charge different prices based on pre-existing conditions.”
• Obama, like the other Democrats, supports the establishment of “medical home” type models to streamline care of the chronically ill.
• One policy that sets Barack Obama apart from the other Democrats is his endorsement of drug re-importation as a means to help lower drug costs. His campaign did not reply to questions about which federal agency would oversee the safe re-importation of prescription drugs.
• Unlike the other Democratic candidates, he also proposes to reform medical malpractice by strengthening antitrust laws to prevent insurers from overcharging physicians for malpractice insurance.

The Republican Candidates

As a whole, the Republican Candidates do not address insurance discrimination, catastrophic coverage, NIH funding, or stem cell research. They generally propose to increase the number of insured individuals by increasing competition among insurers, providing tax incentives to individuals to obtain insurance, and lowering the cost of health care.

Rudy Giuliani

• Giuliani hopes to expand insurance coverage through changes to the tax code, by providing a $7,500 individual ($15,000 for families) tax credit to purchase private insurance policies. He opposes individual or business mandates to buy or provide insurance. For low-income individuals, he proposes a “health insurance credit.” Like McCain, he also endorses allowing people to buy insurance across state lines.
• He proposes to curb medical liability expenses with a “commitment to end frivolous law suits.”
• Giuliani would like to “infuse incentives in insurance markets that promote better outcomes for chronic diseases,” but does not provide any additional detail.
• One policy that sets Giuliani apart from the other candidates is that he would like to streamline the FDA approval process for new drugs.

John McCain proposes to broaden the number of insured in the following way:

• In order to make it possible for more individuals to obtain insurance, McCain proposes to provide a $2,500 tax credit for individuals ($5,000 for families), to incentivize those who can’t obtain insurance through their employer. He proposes to allow people to purchase insurance nationwide, across state lines, which he hopes will increase competition and lower premiums. To help contain costs, McCain proposes aligning Medicare reimbursements to the bundle of service provided, rather than to each procedure performed.
• McCain would like to encourage preventative services and better coordination of care for the chronically ill by reforming the payment systems of Medicare to compensate providers for diagnosis, prevention, and care coordination.
• To help keep drug prices under control, McCain would like to “develop safety protocols that permit re-importation.” His campaign did not reply to questions about which federal agency would oversee the re-importation of drugs.
• Finally, McCain proposes tort reform in the form of capping medical liability for doctors.

Mitt Romney, who as Governor of Massachusetts pioneered that state’s health care plan requiring individuals to purchase insurance, is opposed to a national version of his plan for Massachusetts.

• His plan would give states the autonomy to develop market-based health care programs, by de-regulating state insurance markets, which he expects to bring down costs. Like the other Republican candidates, he would also like to change the tax code, to allow individuals to deduct health insurance premiums and out-of-pocket medical expenses. For low-income individuals, Romney proposes re-directing federal spending on “free care” to help these individuals purchase private insurance.
• Romney proposes medical liability reform by placing federal caps on non-economic and punitive damages.