The third session of the World Health Care Congress was begun by a talk from Rep Jim Cooper (D TN), one of Barack Obama’s health policy folks. Rep Cooper primarily condemned Sen McCain’s policy, while noting that both Democrats’ platforms were essentially identical – with one notable exception – Obama does not mandate coverage.
(A comparison of the Clinton and Obama plans is here)
According to Cooper, the upfront problem w universal coverage is that it will result in “zero Republican votes” – a completely wrong statement. For example, Ron Wyden’s (D OR) Healthy Americans Act has six (6) GOP cosponsors – and the HAA specifically calls for universal coverage.
McCain’s spokesman, Thomas Miller of the American Enterprise Institute, talked a good bit about the tax implications of McCain’s plan – a program that is remarkably similar to Pres. Bush’s plan (that got absolutely zero traction in Congress). Miller noted that McCain’s plan relies on the market and individual motivation to buy insurance, a motivation that will be enhanced by a tax credit for those how buy coverage (a tax credit that amounts to $2500 for an individual or $5000 for a family, about half of what coverage actually costs).
I’d note that Mr. Miller did not mention that Sen McCain’s plan will also be quite expensive. The cost of the Senator’s tax credits would be $206 billion in FY 2009 and $3.6 trillion over 10 years.
Chris Jennings spoke for Sen Clinton, and he started with the (I would argue sole) difference between the Clinton and Obama plans – she wants mandated universal coverage and he does not. Mr Jennings noted that half the cost comes from rolling back the Bush tax cuts and half from programmatic savings, but he did not add much in the way of new insights into how Sen Clinton’s plan will reduce costs.
There were two commentors – George Halvorson, CEO of Kaiser Permanente, and fomer Sec of State (and other departments) George Shultz. Halvorson began with the good news, that candidates are talking at a level of detail and comprehension re health care that is unprecedented. We’ve moved away from sound bites and deep into the details, a transformation that is quite encouraging to Mr. Halvorson.
George Shultz noted that if people work longer there will be more GDP, and this will help pay for more health care. He also opined that the reason people are living so much longer over the last 60-80 years is due to basic research and development of technology and pharmaceuticals. This, I would note, is in direct conflict with every other expert’s view on the subject – sanitation, nutrition, antibiotics and infectious disease control are overwhelmingly responsible for the improvement in lifespan, not MRI machines and new drugs (with the notable, but not overwhelmingly important, exception of antibiotics).
Finally, someone raised the question of comparative effectiveness evaluation – and all spokesmen agreed that we need to do a lot more of it. The elephant in the room is the AMA, and their likely-nuclear reaction to anything that smacks of ‘telling physicians how to practice medicine’.
But here’s my primary takeaway – everyone on the panel called for universal coverage even if McCain’s spokesman’s support was muted at best.

Health care ‘experts’ are coming out of the woodwork like termites after fumigation. Former Sec of State George Shultz and Stanford professor John Shoven are two of the latest emergent experts; they have written a book on reforming social security and health care – I haven’t read the social security part and after reading the health care section I don’t think I will.
One of the authors’ primary contentions is that involving the consumer in health care is a key to reforming the system. One of the bases for their argument is the history of laser eye surgery – Shultz and Shoven contend that the consumer’s involvement in selecting and negotiating for laser surgery demonstrates that consumerism can reduce costs while improving outcomes.
This because health insurance does not pay for lasix, forcing consumers to, well, be consumers. The huge differences between buying eye surgery (a pretty basic decision, with a tightly defined problem and expected outcome and easily measured result) and figuring out how to buy, or more accurately if you need to buy, health care for your child with an undiagnosed neural disorder are not addressed – at all. I find this to be an unforgivable error, an oversimplification of monumental proportion.
They call for risk adjustment as the way to spread risk and require insurers to take all comers for Medicare and Medicaid members, and seem to advocate universal coverage, but don’t adequately address, or I would argue even minimally address the issue of adverse selection. This issue – adverse selection – is central to the problem of health insurance today – people who need insurance buy it, and the sicker they are the more they are willing to pay, and the more expensive it is, the fewer healthy folks will sign up (because the cost:benefit doesn’t make sense). This is the death spiral – a current example is Humana, currently getting murdered in Part D (they are one of the only payers still offering a rich option, others have dropped the Cadillac plans because, surprise, the people who bought them were the ones who needed the most, and the most expensive, drugs.
What does this mean for you?
Listen to people like Bob Laszewski, Uwe Reinhardt, Alain Enthoven. People who know of what they speak.

The opening session for the World Health Care Congress featured Hans Rosling MD PhD of Sweden’s Karolinska Institute – a wizard in the use of statistics to explain the relationship between income, health status and the evolution thereof in ways that enable regular people to quickly and readily grasp the issues.
According to Rosling, the biggest disconnect between reality and our current perceptions there of is our segmentation of countries into ‘developed’ and ‘developing’, a segmentation that we use (that ‘we’ would include me) that now looks to really miss the mark – and not by a little.
There is no difference between the Western and developing worlds in two key areas – fertility rate and life expectancy at birth – this has been a remarkable change over the last 50 years, due to fewer kids, better sanitation and nutrition. Pretty simple stuff. But big in terms of implications – for example, demographically, Vietnam is precisely where the US was in 1980 – in terms of family size and life expectancy. And these changes happened before significant economic changes in Vietnam, changes that one would normally associate with dramatically improved population health status.
Most economic growth in the world is taking place in developing countries, the countries that make up 60% of world population and earn a quarter of total income. Yes, we still have about a billion poor people, but that number has remained static for over a hundred years – the percentage of the population that is poor has dropped dramatically.
Rosling’s presentation also made a very convincing case, or more accurately proved, his point that there are wide disparities between and among countries in the same areas – making general statements about OECD v Developing countries is not only dead wrong, it is misleading. Misleading in that we draw conclusions based on a split that appears to be deep and persistent, when in fact the ‘developing’ world is growing faster, economically and in terms of health status, and is rapidly catching up to the developed world.
What does this mean for you?
Always question your assumptions.

I’m covering the World Health Care Congress in D.C. today, and will be posting from the front row. I’ll start with the intro keynote, and post on each session separately. Here’s the order
1. Global Health Trends
2. Interview w George Shultz and Dr John Shoven on their incremental approach to reforming health care
3. Presidential Health Care Agenda – spokespersons from the three candidates left standing
4. Innovation in health care – with Clayton Christensen, perhaps the most insightful business author I’ve read in years
5. HealthGrades on Search and Transparency
6. Achieving accountable care – Elliott Fisher (Dartmouth) Mark McClellan, American Enterprise Institute
To those who subscribe, you will be inundated with posts today.