For some time I've been noting that Clinton hadn't put out her health care proposal. Now she has (PDF) and it's a decent one. Oh, it's not great, because it's not single payor health care, but then, no one is offering single payor.

This isn't a universal health care plan -- it's a universal insurance plan. The difference is that in the first you just get health care, not insurance (if I need to go to the hospital in Canada odds are I will never see a bill for care. Nor do I ever (other than my tax return) ever see a bill for "health insurance").

What it does is allow Americans to buy into both government and private plans, including the very best plans offered to Senators. It forces insurers to accept people with pre-existing conditions, people from hazardous occupations and people with significant health care costs. It forbids charging different fees based on age or gender. It requires renewal to be automatic if an enrollee wants to continue and can pay, and it enforces guaranteed issue -- if someone applies and can pay, they must be enrolled.

What I think this means (assuming I'm reading it correctly) is essentially the end of underwriting. As a result people who are low risk, men, young people and so on will probably see somewhat higher insurance fees, assuming they aren't offset by the reduction in costs from various rationalizations and from the elimination, or near elimination, of the underwriting function. A lot of other people, especially those who need the insurance the worst, will see sharp decreases in premium costs.

Because this is an insurance plan, not a health plan, Clinton has included substantial tax credits to keep the cost of insurance low for those who are poor, capping the percentage anyone can ever have to pay for insurance. And for the truly destitute she has promised to expand Medicaid coverage.

There are also some administrative fixes such as improving the computer networks serving health care providers, stopping overpayments, and so on. They all make sense, and while one might quibble with the question of whether all expected savings will be actually be achieved, none of them are bad ideas.

Perhaps my favourite little tidbit is the intention to spend a good chunk of money on testing treatments against each other. One of the great problems with current testing is that all you have to show, for example, is that a drug is better than a placebo -- not that it is better than other drugs or treatments. As a result we generally don't know which drugs in the same class are best for treating various conditions: it's just a crap shoot.

The most brilliant part of the package is the "legacy health care plan." A lot of private insurers *cough, GM, cough*, have horrible legacy health care costs because of health care benefits guaranteed to retirees or aging work forces. These costs are part of what is making certain companies and industries uncompetitive. Clinton proposes to give tax credits to such companies to offset the cost, which is only fair and will help them get back to fiscal health and be competitive again.

Still, while there are details, there are lot of unanswered questions. These are the questions (along with explanations of why they matter if necessary) I sent to the Clinton campaign yesterday. Whether this plan is "better" than the Edwards or Obama plans will depend on the answers to these questions. Clinton's policy team is understandably swamped with requests, so I have no answers yet, but when I get them (or if I don't) I'll share what I learn with Agonist readers.

Questions, and why they matter, after the jump

1) Does "guarantee issue" apply to all health insurance plans or just subset of plans (i.e., just to the ones on the "health choices menu")?

Why it matters: if they don't apply to all, the plans not covered will cherrypick the healthy people and leave the sick people to the regulated plans, which will make them massively expensive. If this is allowed the plan won't work -- this is the most important question of all, because it can potentially turn what would be a good plan into an absolutely awful one.

2a) Are you allowing premium ratings by healthiness (e.g., many insurers give people "health ratings" and then asses costs based on how likely they are to get sick)? I notice age/gender/occupation will be forbidden and you have to issue, but can you in any way charge more for the sickees?

2b) (Is this the end to underwriting? What sort of underwriting will still be allowed and for which plans, if any?)

Why it matters: If you can't charge for people who will (on average) incur more costs then premiums will, as noted in the main text, go up for many people. I don't have a problem with that, but it's an interesting choice and will be used to attack the plan.

3) The plan includes independent research to determine effectiveness of different treatment types. Are there any plans to use this to determine formularies on the public plans?

Why it matters: Choice is a bugaboo. Giving people the option of choosing less effective medicines because they've seen too many ads on TV isn't doing them any service.

4) Have you done the numbers on whether increasing insurance premiums for making insurers take people with pre-existing conditions and bad indicators (who are likely to be sick) will be offset by decreased underwriting costs?

Why it matters: sick people have to be paid for. If a person with cancer that is going to cost 2 million bucks to treat can buy insurance for less than 2 million bucks, someone's got to pay. Again, I think this is the right thing to do, but it will increase costs for other insureds (though not for society as a whole). However those costs may be offset by savings elsewhere.

5a) Does the "individual responsibility" mean an individual mandate (e.g., are people forced to buy insurance)? What if someone loses a job or some such, and irrespective of "tax credits", which after all don't come immediately, can't afford his or her next month's premiums?

5b) Do I understand that Medicaid would be properly funded to take care of the poorest adults who don't fall under Medicare or programs for children?

Why it matters: Tax Credits don't always cut it. If you don't have money "now" so you can't pay the bill, well, you could die. This is one reason I don't like universal insurance compared to universal health care. Individual mandates also mean people are being forced to buy something, and that makes me twitchy and it is likely to turn many people against this. Being forced to buy yet something else, when so many Americans are stretched thin, is not smart. Again, universal health care (not universal insurance) would be better.

6) Doesn't this plan still lead to poorer people not having as good an insurance as richer people? Would there be cases where you'd be better off being poor so you could get Medicare, if truly ill.

Why it matters: I'm wondering where the floor is.

7a) If Medicare is allowed to negotiate lower drug costs, is it allowed to remove drugs from the formulary if necessary? Can it insist on the use of drugs that are equally effective rather than allowing "choice" of expensive drugs for which there is no evidence there is better performance over cheaper ones?

7b) Any plans to make other changes to Medicare Part D?

Why it matters: if you can't kick people out of the formulary, you can't really negotiate. It's just that simple. And Medicare Part D is a disgrace that is far more expensive and complicated than it needs to be.

As soon as I have answers to these questions, I'll report back to Agonist readers.