Hillary Clinton made a major speech on health care yesterday. (Here’s the full text). Her quick points. Pay for preventative services (although what she’s talking about you’d recognize as DM), use IT and EMR, use the primary care “medical homes model” (the AAFP’s got to her!). Those are all strategies to save money—suspend your disbelief for a moment. Her other points are about changing malpractice and beating up drug companies on pricing. All very worth and all that but mostly rhetoric I guess.

Then more interesting stuff. Basically she wants a re-run of 1993–4. Big purchasing pools for small business. Guaranteed issue at community rating. Ending risk selection and underwriting. Unfortunately she uses a bad example by conflating cherry picking with insensitive network management/UR which are NOT the same thing:

In fact, according to a recent McKinsey report, insurance companies in America spend tens of billions a year figuring out how not to cover people — doing complicated calculations to figure out how to cherry pick the healthiest persons, and leave everyone else out in the cold. That is how they profit: by avoiding insuring patients who will be "expensive" — and then trying to avoid paying up once the insured patient actually needs treatment.

I see this all the time. My office spends countless hours arguing with insurance companies to get my constituents the health care they have paid for. For example, a father called me from northern New York — his son had a rare illness. Now he and his son were well insured. He’d worked for many years for the same employer who provided a good policy. But when his son needed a special operation — that could only be performed at one place in the country — the insurance company said, sorry, that’s out of network, we’re not going to send you to have that done. So my office intervened. And in the end they got permission for the operation. But I don’t think people should have to go to their United States Senator to get their insurance company to give them what they’ve paid for.

As President, I will end the practice of insurance company cherry-picking once and for all by allowing anyone who wants to join a plan to do so and prohibiting insurance companies from carving out benefits or charging higher rates to people with health problems.

She needs to find a new example to educate people as to what cherry picking is. Perhaps she should take Jon Cohn tour with her…. In any event that coverage denial piece will come back to bite her because her most interesting issue is her desire to establish a NICE type cost effectiveness institute which she calls the Best Practices Institute, and she gives a strong hint that it’ll not just be vetting new drugs for cost-effectiveness but also be using Wennberg/Dartmouth-type analysis as well as standard cost-effectiveness analysis to direct P4P. So of course there will be coverage decisions which may impact that constituent of hers with a rare illness…

It seems to me that she’s trying to get on the wave of employer discontent and then cut a deal with the larger insurers to let them stay in the game, and also let them blame the government (the new Best Practices Institute) for restrictions on coverage decisions. Not a bad political compromise perhaps. Of course the devil is in the details of the pools and the uniformity of benefits that insurers must provide.

And of course the real thing that needs discussion is the one thing she left out. How does this plan get the uninsured insured? It keeps the same employer payment format in place, and seems to have no mandate. Hillary is many things but dumb is not one of them. She must be focus grouping this next element to death, because ignoring it isn’t an option, even for as corporate a Democrat as she’s become.

Still, she’s revealed more than I expected her to, and there’s plenty here for her opponents on the right as well as on the left to latch onto. This is getting fun!