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John Edwards answers questions from AHCJ members

Election 2008

See AHCJ's Election 2008 resource, with news and links to the candidates' statements about health care issues.

1) Should there be universal insurance coverage in this country?

Yes, absolutely. Politicians have to stop using code words like 'access to health care' when they know with certainty those words mean something less than universal care. Who are you willing to leave behind without the care she or he needs? Which family? Which child? We need a truly universal solution, and we need it now.

I was proud to be the first major presidential candidate to propose a specific plan to guarantee quality affordable health care for every man, woman and child in America. My plan is truly universal.

2) If you believe in universal insurance coverage, how would you achieve it (i.e., employer mandate, individual mandate, single paper)?

Under my plan, businesses will either cover their employees or help pay their premiums. The government will make insurance affordable through new tax credits and by leading the way toward more cost-effective care. New "Health Care Markets" will give families and businesses purchasing power and a choice of quality plans, including one public plan. Finally, once these steps have been taken, all American residents will be required to take responsibility and get insurance.

Over time, the system could evolve into a single-payer approach if enough Americans choose the public plan.

With my plan for true universal health care, families without insurance will get coverage at an affordable price. Families that have insurance today - who sometimes have trouble paying their share of health insurance payments - will pay less and get more security and choices. Businesses and other employers will find it cheaper and easier to insure their workers. I have proposed steps that will save an average family $2,000 to $2,500 a year and eliminate at least $130 billion a year in wasteful health care spending.

3) Should private insurance companies be allowed to choose who they want to insure, taking into account a person's age and health status

No. I will require insurers to keep plans open to everyone and charge fair premiums, regardless of preexisting conditions, medical history, and other characteristics. No longer will insurance companies be able to game the system to cover only healthy people. Several states - including New Jersey, New York, and Washington - have led the way on similar community rating and guaranteed issue reforms. In addition, new national standards will ensure that all health insurance policies offer preventive and chronic care with minimal cost-sharing.

4) If you or someone else in your family has ever been uninsured, what was that experience like?

I am deeply grateful that my family has always had health insurance. My mother worked for the U.S. Postal Service and she and my father got health care because she was a member of the Rural Letter Carriers Association. Since my wife, Elizabeth, was diagnosed with breast cancer, having health insurance has taken on a new level of importance for us. I want anyone who faces a diagnosis like Elizabeth's, or any other illness, to have the same high quality care that she has received.

Presidential candidate John Edwards5) Explain why your approach for reducing the nation's health care costs would succeed?

Reducing costs is essential to achieving true universal health insurance and it is a critical goal of my health care plan. My plan will cut waste in the insurance and drug industries and invest in cost-saving steps like chronic and preventive care to eliminate at least $130 billion a year in wasteful health care spending and reduce the cost of a typical family policy by $2000 to $2500 a year.

Under my plan, businesses will either cover their employees or help pay their premiums. The government will make insurance affordable through new tax credits and by leading the way toward more cost-effective care. New "Health Care Markets" will give families and businesses purchasing power and a choice of quality plans, including one public plan. Finally, once these steps have been taken, all American residents will be required to take responsibility and get insurance.

Universal coverage will bring down premiums for employers that provide insurance today. The cost of caring for the uninsured adds $922 to an average family policy. Guaranteeing universal care will end irrational cost-shifting, the practice of providers charging more to those with insurance to cover uncompensated care.

Employers can choose to enroll their workers in Health Care Markets, which will bring down costs through negotiating power and administrative efficiencies. Giving individuals in Health Care Markets a choice of insurance plans including a public plan will force private insurers to operate in a more competitive market, holding down costs and improving care. If families find that the public plan offers the best care at the best price, the system could evolve toward a single payer approach.

6) How would you put Medicare on a solid financial footing for the rest of the century?

Skyrocketing health care costs have put pressure on Medicare and threatened its longterm solvency. The Medicare trust fund is projected to be exhausted in 2019. Instead of strengthening Medicare for our seniors, George Bush has surrendered it to the drug companies and HMOs. The first step toward extending the life of Medicare is universal health care reform that makes health care more cost-effective, including investments in preventive and chronic care, electronic medical records, and promoting proven costeffective care. Within Medicare, I will clamp down on skyrocketing drug costs and stop the overpayments of insurance companies, using the savings in part to ensure that Medicare beneficiaries have access to the care they need.

7) Should the government allow those 55 and older to buy into the Medicare system at their own cost?

Under my plan for truly universal health care, everyone will have health care coverage they can take with them from job to job, or in to retirement. My health care plan will also guarantee quality, affordable coverage for older Americans who transition to temporary, part-time or independent work but are not Medicare-eligible.

Older Americans not yet eligible for Medicare but who do not receive coverage from an employer will be able to purchase health insurance - either a private plan or a public plan based on Medicare - through Health Care Markets. Tax-credit subsidies will be available to ensure the plans are affordable.

8) Will pay-for-performance plans, in which providers are paid based on their quality scores, further stratify the disparity between rich and poor patients?

So-called pay-for-performance plans have the potential to unintentionally exacerbate health care disparities if they are not well-designed. In particular, compensation schemes that reward physicians solely based on patient outcomes or are implemented only by private health care insurers may lead to the best private physicians seeing only more affluent patients.

As part of my proposal to transform our health care system and guarantee quality, affordable health care for every American, Medicare, Health Care Markets, and other government programs will lead the way by paying higher rates to plans and providers that provide the very best care and penalizing plans that fail to meet critical, quantifiable goals such as childhood immunization rates.

Our health care system is predominantly fee-for-service: providers are paid for each treatment, regardless of its necessity or quality. For example, a hospital that makes a medical error is often paid for the error and then paid again to fix it. Our system should pay for results, rewarding better, more efficient care.

9) What should the U.S. national policy be for paying for long-term care?

The federal government has an important role in ensuring that every man, woman and child in America has quality, affordable health care, including long-term care in the least restrictive setting possible.

I will reform Medicaid and Medicare to let people to choose home-based care in their communities and test innovations such as asset and income protection programs. I will also support states and communities offering much-needed and often less expensive alternatives - like adult day care and senior villages - that allow seniors to live at home with their loved ones.

Independence is the goal, but we also need to strengthen quality and safety protection in nursing homes. I will establish national standards for nursing home care, increase national enforcement against abusive nursing home chains, expand inspections and increase penalties for homes that fail to provide decent care. I will also help improve quality of care with measures like reducing patient-staff ratios and improving care provider training.

To help relieve the strain for families caring for loved ones, my health care plan also supports respite care.

To help families save for long-term care or other retirement needs, I will require employers to offer all workers without another pension access to a new universal retirement account, letting them build up savings no matter how many times they change jobs. The government will match worker contributions up to dollar-for-dollar on the first $500 with a new tax credit.

10) What steps should the federal government take to reduce obesity and diabetes, which are looming as the greatest threats to public health?

It is time to invest more in prevention. Diabetes alone cost Americans $132 billion in direct and indirect medical costs in 2002. My plan provides preventive and chronic care (including medications) with no deductible and little or no co-payments. Focusing on proactive treatment will save our health care system billions of dollars and ease the burden of preventable conditions that eventually end as expensive trips to our emergency rooms and costly hospital stays. I will also promote the techniques of the Diabetes Prevention Program in private plans and require the use of its best principles in public programs.

I will take aggressive steps to revolutionize the treatment of chronic conditions. I will require insurers offering health plans through Health Care Markets and other public plans to manage chronically ill patients' health across all their product lines in order to avoid unnecessary problems and hospitalizations. The Health Care Markets will also promote disease management programs. For example, to better treat diabetes, plans will ensure that doctors regularly check up on their patients with diabetes and treat them proactively, cover nutritional counseling, and help them monitor and control their blood sugar levels.

Obesity is now an epidemic in the United States. The choices we make about food, work, play, and our environment have significant consequences on our lifestyle and health. I will ask individuals, families, schools, employers, and officials from all levels of government to share responsibility in addressing this epidemic. I will work with schools to remove unhealthy foods, support physical and healthy lifestyle education, encourage worksite programs to promote better health, and encourage healthy lifestyles.

11) What further steps need to be taken to protect U.S. citizens in the face of a global pandemic?

As Hurricane Katrina clearly showed the American people, our government needs serious help in preparing for another natural disaster or global health threat. I believe we must improve our preparations and my plan will create better national leadership, coordination and accountability in how we prepare for and effectively respond to natural disasters and global health threats.

To address global health issues such as epidemics and those caused by natural disasters. I will create a single disease control office with authority to direct and coordinate the government's response to disease outbreaks. There are currently multiple Cabinet departments and government offices are involved in coordinating the response to disease outbreaks. This bureaucracy prevents adequate planning and fast response to crisis. This new office based at the Department of Health and Human Services will closely coordinate with state and local officials as well.

Even after September 11th, fiscal challenges have forced many states to cut support for public hospitals and health departments. While states have started to devote money to public health, shortcomings remain. I will offer additional federal support to states to build their public health systems, including strengthening lab capacity.

Currently, it takes several days for the government to learn about two key factors in any disease outbreak: the progression of the disease through different communities and the availability of vaccines to respond to the disease. I will establish a real-time, unified national tracking system for diseases and vaccines. That system will be easily accessible to public health officials so they can learn how a disease is moving and where to get vaccines.

Today, it takes months to produce flu vaccine, making it impossible to respond to an immediate need. I will direct the National Institutes of Health to research more efficient vaccine production methods. While we have avoided shortages in the past two years, system failures in 2002 and 2003 show that better infrastructure is needed to make the system work.

12) What will you do to ensure that federal agencies are performing research based on scientific models and reporting information objectively on controversial health issues of the day?

Only a small fraction - likely less than 0.1 percent - of each health care dollar is currently devoted to systematic research and assessment of the comparative effectiveness of various diagnostic and therapeutic options. I will establish a non-profit or public organization - possibly within the Institutes of Medicine - to research the best methods of providing care, drawing upon data from Medicare, Health Care Markets and medical experts from across the nation. It will test devices and drugs head-to-head to see which work best and for whom. This new organization will quickly and widely disseminate its unbiased, scientific findings to physicians and patients.

Though we have some of the best health care technology in the world, effective new treatments can take years to be widely adopted. For example, until recently, many patients did not receive beta blockers after heart attacks even though they are cheap and highly effective. Similarly, doctors sometimes prescribe name brand drugs despite the availability of equally effective, less expensive generic drugs. As new diagnostics, procedures and drugs are introduced, my new objective medical research organization will help doctors make sense of what works best. Government programs will offer incentives for the use of evidence-based care and treatments.

We need to step up our research efforts to find the causes of illnesses, as well as better treatments. And that research must be transparent, accountable and be driven by science, not ideology.

It used to be that close to five out of 10 requests for National Cancer Institute grants were approved. Now it's less than two out of 10, and existing grants are being cut back. The answers to the problems we face could be somewhere in the eight we turn down. I support substantial increases in funding for the National Science Foundation, the National Institutes of Health, and other ongoing initiatives, as well as measures to ensure transparency in funding decisions, accountability for results and align research with outcomes.

I believe that policy should be science driven, and that science shouldn't be politics driven. Ideological debates have drained resources from promising research. I will increase funding for and lift stifling research restrictions on embryonic stem cell research, while banning reproductive human cloning.

13) How would you change the financial incentives in health care to reward improvements in the actual health of patients, rather than linking reimbursements to the number of procedures performed?

Our health care system is predominantly fee-for-service -- providers are paid for each treatment, regardless of its necessity or quality. For example, a hospital that makes a medical error is often paid for the error and then paid again to fix it. Our system should pay for results, rewarding better, more efficient care. Under my plan, Medicare, Health Care Markets, and other government programs will lead the way by paying higher rates to plans and providers that provide the very best care and meet quantifiable goals such as childhood immunization rates.

I have also proposed the expansion of the use of advanced medical homes. We need a renewed emphasis on the importance of primary care and case management. The U.S. health care system is highly fragmented and centered around episodic care - people get care only when they get very sick. There is little integration of care, with little incentive for physicians to provide coordination. Typically, physician visits are short and focused on diagnostics, not the wellness and education that a chronic disease requires. This situation puts everyone at risk. Many patients with chronic conditions receive care that is sometimes redundant, or worse, counter-productive. Research compiled by the American College of Physicians shows that patients who receive greater levels of primary care are likely to have fewer complications and receive better chronic care.

I will direct Medicare to develop new payment systems to help make sure that beneficiaries have a medical home with a doctor who knows them and coordinates their care. Medicare will lead the way in developing the best ways to care for individuals.

14) How can the government narrow health care disparities among ethnic and economic groups and people living in different regions?

Low-income families, limited English language speakers and people of color are less likely to receive quality care. For example, because people of color are more likely to be diagnosed with cancer and less likely to receive timely and effective treatment, they also experience higher cancer mortality rates.

I will support medical research into disparities so we can effectively target our resources to improve, reduce pollutions and toxins that disproportionately harm low-income areas and communities of color, and invest in translation services to address language barriers that can impede care or cause medical errors. I will also address disparities in health caused by disparities in insurance by implementing universal coverage. And, because disparities persist today even among Americans with health insurance, I will make sure all health providers implement evidence-based medicine that makes best practices contagious.

The quality and quantity of care Americans receive often depends more on their zip code than their health needs. If health care in all states performed at the same level as the five best performing states, the American health care system would have outcomes as good as any system in the world. Spreading proven best practices from a few pockets of excellence to the entire U.S. health system is a critical step in improving outcomes. I will develop partnerships among academic medical centers, Medicare, and other federal agencies to disseminate best practices and make sure every American has access to high quality care.

15) Who should bear the cost of hospital-acquired infections and medical errors?

I will provide incentives for quality and reducing medical errors. Under the fee-forservice model, a hospital that makes a medical error is often paid for the error and then paid again to fix it. Under my plan, Medicare and other federal programs will lead the way in paying for performance.

I will also help prevent medical errors by implementing a voluntary medical error knowledge bank, creating a new objective medical research organization that disseminates best practices, incentives to make those practices contagious, giving doctors tools to improve communication, transforming primary care delivery to ensure care is coordinated, supporting technology and infrastructure like automated medication dispensers, and establishing and publishing basic quality benchmarks.