Conference Call/Webinar: Women's Health Care
On Tuesday, December 18th, at 3pm EST the Progressive States Network and the National Women's Law Center  will present policy options state lawmakers can pursue to improve women's health and health care.
The webinar/conference call  - Making the Grade on Women's Health: Where Do We Go from Here? - is the result of a new report  providing a comprehensive analysis of state progress towards the Healthy People 2010 goals for women's health. The webinar will feature Judy Waxman, Vice President, Health and Reproductive Rights at the National Women's Law Center. She will discuss policy options that states can adopt to improve women's health and explore how to use the report findings as a platform for health care reform.
Presidential Platforms and State Policies
Given the experience of Senate filibusters against innovative policies proposed at the federal level, here at Progressive States we are inevitably cautious  in our hopes based on Presidential candidate proposals.
But state policymakers can in many cases adapt the best of the candidate proposals for state laws-- and in many cases already have done so, since as this Dispatch will outline, many of the best ideas proposed by the candidates are already part of the debate in the states. This issue will focus on three areas -- energy policy, health care, and aid for working families -- where states can adapt candidate proposals.
As we've emphasized in the past, a healthy energy policy must include weaning us off of foreign oil, developing and promoting renewable energy , and taking serious steps to fight global warming . While some states can take elements from the Presidential candidate plans, the most striking part is that none of the candidates are offering anything that is more bold or more daring than what is already happening in the states.
Cap and Trade: Many of the candidates are supporting expanded cap and trade systems  to decrease the amount of greenhouse gases released into the atmosphere. There are already several regional cap-and-trade programs  in place and a federal cap and trade  plan, as proposed by many of the candidates, would mostly widen participation
Joe Biden, Hillary Clinton , Chris Dodd  (who also supports a carbon tax), John Edwards , Dennis Kucinich , Barack Obama all support a cap and trade system to cut U.S. emissions by 80% below 1990 levels by 2050. Bill Richardson  supports a goal of cutting emissions by 90% below 2006 levels by 2050.
Mike Hukabee  supports a cap and trade system but has not come out with any specifics. John McCain supports a cap and trade system and is the co-author of the Climate Stewardship and Innovation Act  with the goal to reduce emissions by roughly 30% by 2050.
Rudy Giuliani does not support a cap and trade system. Mitt Romney also doesn't support a cap and trade system, even though Massachusetts was involved in the development of the Regional Greenhouse Gas Initiative  - the country's largest and first regional cap and trade program- during his tenure as governor. Romney ultimately backed out of signing it, but thankfully Governor Deval Patrick signed the state back into  the compact at the beginning of this year.
Fuel-Economy Standards for Automobiles: The federal bill  that just passed the Senate calls for the first major increase in automobile fuel efficiency in 32 years. The bill requires car companies to achieve an industry-wide average of 35 miles per gallon (mpg) for cars, small trucks and SUVs over the next 13 years. Many of the presidential candidates have much higher standards:
Obama  has a weaker standard that calls for 40 mpg for cars and 32 mpg for light trucks by 2020.
Romney has an unsatisfying plan  that opposes raising fuel-economy standards on their own but has ideas for making U.S. cars more fuel efficient.
While raising fuel economy standards will help reduce carbon dioxide emissions, California  has a much better way of ensuring decreased emissions by regulating the amount of carbon dioxide emissions from cars and trucks instead of a mpg standard. As a result, to meet their emissions requirements, the fuel economy of cars must be raised to an average of 43.5 mpg -- much higher than the federal regulation that just passed. The regulation was challenged in court by automakers, but a judge recently ruled  in favor of the state.
Renewable Energy Development: Renewable energy development seems to be the one area that all candidates  support. Among those that have specific proposals, Richardson has the highest target with 30% of electricity to come from renewables by 2020 increasing to 50% by 2040, otherwise known as a renewable portfolio standard  (RPS). The other candidates with specific targets call for RPS's that range between 20- 25% of all electricity to come from renewables.
Biden  supports investing $50 billion over five years into developing renewable energy technology. Clinton  supports a $50 billion 10-year fund while Obama  proposes investing three times that amount at $150 billion over ten year. Edwards  supports a $13 billion a year investment fund.
By far, Dodd  has the most expansive plan proposing to invest $50 billion every year through funds that are generated through his proposed carbon tax.
There's a lot of catch up to do on the federal level with regards to renewable energy. Twenty-five states, plus the District of Columbia, already have  a mandatory RPS and three others have voluntary standards. Of those, at least half are as high, or higher, than what the candidates are proposing.
Health Care Reform
Health care is the number one domestic concern for Democratic, Republican, and unenrolled voters. It is no surprise that candidates for president are offering decidedly different approaches to fixing our country's worsening health care woes.
Most of the Republicans  largely tinker around the edges of the problem, using a mix of tax credits and incentives for families to purchase non-group health insurance. Unfortunately, many of their proposals would weaken state reforms that help consumers find comprehensive and affordable insurance options.
Democrats , with the exception of Dennis Kucinich's universal single-payer plan, pursue a decidedly public-private approach to reform by expanding public programs, creating large purchasing pools, and offering sliding scale subsidies to help families afford individual and employer coverage.
What is of interest to state policymakers is that there is little in the presidential candidate proposals that isn't already being pursued in the states. Many of the proposals incorporate or build on what states are pursuing, making it clear that states should continue working towards comprehensive health care reform as any federal system will likely have a strong state-federal link.
The Problem of Affordability: The affordability of health care coverage is front and center in the health care debate with candidates of both parties proposing affordability measures including tax credits, tax incentives, or sliding scale premium subsidies.
Democratic presidential plans  would largely pair sliding scale premium subsidies to both individuals and employers with stronger consumer protections. To increase affordable options, Biden, Clinton, Dodd and Richardson would explicitly allow Americans to buy-into the federal employees' health plan.
On the Republican side , Guiliani, Huckabee and McCain would provide low-income families with tax credits (although often undefined in their plans or, in the case of McCain, far less than the cost of typical premiums). All three of them, plus Mitt Romney and Ron Paul, support broader deductibility of health insurance costs-- an approach that does little for average families but a boon for wealthier taxpayers. Thompson and Tancredo have vague plans to provide some subsidies, while Duncan Hunter provides no financial help in his plans.
But do the candidates really ensure affordability of health care? Hillary Clinton  is the only candidate to specifically include a provision that annual expenses not exceed a percentage of family income, but this falls short since the limit only applies to premiums, not all out-of-pocket expenses. Active proposals in Wisconsin  and California  are offering comprehensive affordability protections limiting ALL out of pocket costs , including premiums, deductibles and co-pays, to a percentage of income. Dennis Kucinich's universal single-payer plan  goes the furthest to ensure affordability by eliminating premiums and deductibles and setting tax-based financing on a sliding scale.
Guiliani, Hunter, McCain and Tancredo, unfortunately, would undermine state consumer protections in the name of "affordability" in their plans by allowing insurance companies to evade state rules on maternity coverage, mental health parity, and breast and prostate cancer screenings. Romney's plan would not mandate weakening state plans but would use federal money to encourage weakening of state health insurance regulations.
Individual and Employer Mandates: Across the broad, Republicans  oppose individual mandates to purchase coverage and similar requirements on employers to participate, with most of them supporting changes to the tax code that reduce employer incentives to provide health care and instead shift the burden of providing health care towards individuals, with the goal of expanding the individual market and shifting more of the cost-burden to individuals and families. Adding to his "flip-flop" reputation, Mitt Romney  is not supporting an individual mandate that he promoted as Massachusetts governor in 2006.
Mandates get a more welcome reception among the Democratic candidates, with the notable exception of Barack Obama . While most of the Democrats, including Obama, include mandates on employers to participate in paying for coverage or helping to finance expansions and affordability subsidies, there is less agreement around individual mandates. Hillary Clinton, Chris Dodd , John Edwards , and Bill Richardson  would require individuals to obtain coverage. While Barack Obama would require all children to have coverage, he contends  it is unfair to impose an individual mandate before affordability can be ensured for all Americans. As Massachusetts is showing , it is easy to require everyone to have insurance, but it is far from easy to ensure everyone has access to a comprehensive and affordable plan. Of course, the issue of the individual mandate is mute in Dennis Kucinich's plan which would automatically enroll all Americans in a universal single-payer system.
Strengthening Public Programs: Additional contrast between the major Party candidates emerges in how each would treat public programs, like Medicare, Medicaid and SCHIP. While Rudy Giuliani , Mike Huckabee , John McCain , and Fred Thompson  would largely leave them alone, Mitt Romney would block-grant Medicaid and reduce federal Medicaid requirements, opening the door to costly reductions in which benefits Medicaid covers and who is eligible.
Virtually across the board, Democrats would expand Medicaid and SCHIP, though proposed levels fall short of what many states are pursuing, such as New York's expansion of SCHIP eligibilty to 400% of poverty. Additionally, many would open up the federal employee health plan to any American. Notably, Dennis Kucinich's proposal would absorb public programs into the new universal single-payer plan.
Cost Controls and Quality Improvement: Along with ensuring affordability of health coverage, controlling costs and improving quality may be the most important elements of health care reform proposals, although they often receive the least attention.
Proposals by Democrats and some Republicans, notably John McCain  who presents the most detailed cost and quality proposals among the GOP candidates, include: provisions to invest in electronic medical records and other information technology; provider payment based on performance and quality metrics; emphasizing prevention and chronic care management by, in part, providing it at no cost to patients; greater public disclosure of provider, insurance and Rx manufacturer costs and provider's quality of care performance; and, reimportation of prescription drugs which are dramatically cheaper in Canada and overseas.
Most of the Democrats , however, go further by concentrating on reducing profiteering by the insurance industry. They propose stronger consumer protections and requiring insurance companies to spend more of the money they raise from premiums on direct medical care, with John Edwards  requiring that at least 85% of premiums go for care. Hillary Clinton offers a detailed cost-containment proposal  including an independent "Best Practices Initiative" and would limit direct-to-consumer health care advertising. Barack Obama  expressly identifies the reduction of health disparities as a key reform goal and Bill Richardson would limit consumer exposure to medical debt. Additionally, most would eliminate Medicare Advantage overpayments to private insurance carriers.
Republicans on the other hand, place their faith in more individual decision-making by consumers to reduce health care costs. Several would increase the availability of Health Savings Accounts, which are tied to high deductible plans, and Mike Huckabee  explicitly supports increasing the out of pocket costs of individuals to increase their cost-sensitivity, despite studies  showing that such measures reduce both necessary and unnecessary care and can lead to worse outcomes.
Supporting State Innovation: There is little among the Presidential proposals from both parties that does more than what states are already pursuing . In fact, aside from Kucinich's plan, which would have no state administrative or financing role, there seems to be recognition from candidates on both sides that supporting state innovation in health care is important to fixing our dis-jointed system. Several candidates expressly advocate a federalist approach to health care and support greater flexibility of states to implement programs, but in some cases would also limit state regulatory powers over insurance companies.
As families struggle with stagnating wages and the strain of balancing the demands of work and family, some of the Presidential candidates are promoting ideas from the minimum wage to the EITC to family leave that would help families make ends meet.
Minimum Wage: With the increase in the federal minimum wage to $7.25 by 2009, the reality is that twelve states will still have higher rates  than the federal level then-- with a number of others passing the feds over time since their rates are indexed to inflation. Edwards , Obama , Dodd , and Kucinich  all propose raising the federal rate, with Kucinich specifically aiming for a rate of $8.50 per hour and Edwards supporting an increase to $9.50 per hour by 2012. All four plus Richardson and Clinton would link the federal rate to either inflation or to increases in Congressional pay. Indexing the minimum wage to inflation is a good model for states that don't yet index their own rates.
None of the Republicans plan to raise the minimum wage, with Romney  on record vetoing his state's minimum wage increase (a veto that was overridden), McCain  on record filibustering against minimum wage increases, and Ron Paul, Hunter and Tancredo voting against it as well. Thompson did vote for an increase when he was in the Senate in 1996 and Huckabee  signed a minimum wage increase as Governor, although he says he did so only to prevent passage of a constitutional amendment that would have indexed the wage to inflation.
Earned Income Tax Credit (EITC): For low-income workers, Edwards , Clinton , Obama  and Dodd promise to triple the EITC for single workers, extending help to 4 million people, while Obama promises additional increases to single workers paying child support and extending help to families with three or more children. Kucinich  talks about doubling all tax credits for those making $80,000 or less. None of the Republicans talk about EITC, although Ron Paul is on record in favor of eliminating the EITC altogether.
Family Leave and Sick Days: Even as a few states are taking steps towards paid family leave and paid sick days, some candidates are taking bold leadership to assist them. To support state paid leave programs, Clinton  promises $1 billion per year, Obama  promises $1.5 billion per year, and Edwards  promises $2 billion per year with the explicit goal of covering all workers by 2014. Dodd  more generally talks about guaranteeing eight weeks of paid leave for all workers and Richardson  says we should "consider" doing do. Edwards, Obama and Clinton also all support extending the existing three months of unpaid family leave from firms with 50 or more employees down to those with 25 or more employees, bringing help to 13 million additional Americans. Clinton also proposes to restore the right of states to use unemployment insurance to provide family leave benefits -- state flexibility eliminated by Bush early in his Presidency.
Edwards , Clinton , Obama , Biden  and Dodd  would also all support guaranteeing full-time workers seven days of leave each year to care for themselves or loved ones in case of sickness. Richardson  would again "consider" such a plan.
Again, none of the Republicans have explicit plans on the subject, although Guiliani  condemned Clinton for "out of control spending" when she announced her modest paid family leave plan.
Looking at the candidates' plans, it's clear that the states are leading the feds. In the area of clean energy for example, a recent report  summed it up:"Over the last decade, the states, living up to their reputation as 'laboratories of democracy,' have crafted and implemented a series of bold, innovative clean energy policies. And those policies are working." In health care, it seems inevitable that state policy is likely to drive federal debates, much as is happening now with SCHIP.
What is encouraging is that many of the Presidential candidates are adapting some best practices from the states, from renewable energy standards to indexing the minimum wage to inflation. And in a few areas like paid family leave and paid sick days, candidates are legitimately ahead of almost all states, which can in turn be a spur to states to move forward on those policies regardless of whether they may fall prey to filibusters in D.C.
Grist.org - Compare the Candidates 
Progressive States Network - The Fight Against Global Warming: Another Way States Can Rein in Greenhouse Gas Emissions 
Progressive States Network - Promoting Renewable Energy in the States 
Environment America - America's Clean Energy Stars, State Actions Leading America to a New Energy Future 
Congressional Research Service - Automobile and Light Truck Fuel Economy: The CAFE Standards 
Pew Center on Global Climate Change - States with Renewable Porfolio Standards 
Health Care Reform
Progressive States Network - Individual Health Care Mandates and the Problem of Affordability 
Kaiser Family Foundation - Health08.org: Election news, analysis and events  and 2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary 
New York Times - The Presidential Candidates on Health Care 
Economic Policy Institute - What a New Federal Minimum Wage Means for the States 
AFL-CIO, Working Families Vote 2008 
3 Steps Forward
2 Steps Back
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