Blog entry

Krugman: Why The Health Care Battle Is Key

Isaiah J. Poole — Wed, 27 Aug 2008 17:37:16 -0400

Paul Krugman, the columnist for The New York Times, told me in an interview here in Denver that getting a universal health care plan enacted will be one of he most important keys to creating a progressive moment on a whole host of issues.

His reasoning is this: “If you can get universal health care or something close to it in, however imperfect, then the country will never be the same again. It will be something that is an untouchable, and it will make people just understand once again that government can do things to make the society fairer, safer.”

Krugman calls himself a single-payer advocate, but he says he supports a proposal along the lines of the Health Care for America Now plan because “I want something that you can get into legislation fast.”

One of the barriers health care reform will have to overcome is the fear among the public that they would lose access to quality care under a radically changed system. If you can tell people that they can keep the insurance they have now, but they have the option of enrolling in a Medicare-type system that would provide universal coverage without regard to pre-existing conditions, more of the public would be prepared to get behind it.

Krugman’s prediction is that a united progressive movement could get a Health Care for America Now-style plan could get enacted by the fall of 2009 “by not being a purist.”

“One of the things that the Republicans have been good at is thinking a step ahead, playing the log game, setting things up,” Krugman continued. For those who believe that government “is the problem,” as Ronald Reagan famously stated, the strategy was to “starve the beast; deprive the government of revenue so it can’t do staff later on.

The other strategy was to take power away from the union movement, which Reagan began doing during his term. “Unions raise wages, but they also shift the political balance The destruction of the union movement in the 1980s, which was largely a Ronald Reagan thing, did not just undercut the workers’ bargaining power, but it also undercut their political power.”

That is why Krugman agrees that passing the Employee Free Choice Act is critical to the future of progressive politics.

“That is a big enough agenda to keep a Democratic Congress and President busy for a couple of years,”

Krugman says that the kind of presidential candidate that is needed over the next two months in order for progressives to be in a position to have an ally in the White House is one who is espousing “a clear progressive agenda.”

“Bill Cinton in 1992 had this very simple thing: The hard-working people, the people who played by the rules, who try to do it right, get cheated. He had a phrase about people who cut corners and cut deals. And we need to hear that. I think the theory that a broad, post-partisan appeal could lead to a transformative victory appears to have been refuted.”

What Would You Do If You Had Guaranteed Health Care?

Sara Robinson — Tue, 26 Aug 2008 18:56:05 -0400

This was the Campaign for America's Future's Big Afternoon at the Big Tent. CAF took over the Digg Stage (the entire upstairs floor of The Big Tent) for a series of four panels addressing some of the Big Questions we wrestle with here.

One of the highlights for me was Rep. Jan Schakowsky's presentation, which was part of the second hour's health care panel. She cited an avalanche of statistics describing what condition our condition is in (and I don't need to tell you: it's not good). Two in particular leaped out at me. One (which I knew) is that an American dies due to lack of health care access every 30 seconds. The second (which I did not know) is that Americans are being driven into bankruptcy by health care costs at exactly the same rate. Sixty thousand deaths, sixty thousand bankruptcies, every single year.

(Update: A perspicacious commenter points out that Schakowsky's math was a little off. Sixty thousand deaths (or bankruptcies) works out to about one every ten minutes. My bad for not working the numbers out myself before posting them.)

Schakowsky also said that health care hasn't been a hot-button political issue to date because the political conventional wisdom says that nobody's ever lost an election due to their health care position. That, she said, needs to change -- starting with John McCain, whose plan will make things far worse than they are now (as if such a thing were possible).

As an American living in Canada, my permanent resident card (the Canadian version of a green card) entitles me to the services of that country's health care system. I also still see doctors in the US, even though I'm no longer insured there. As a participant in both systems, I've written at some length here and here about the myths Americans tell each other about the Canadian system. Right now, I think there's one important question we could ask Americans that would focus this debate, and take the conversation to the next level. It's this:

What would you do with your life if you never had to worry about health care again?

It's a hard thing for most Americans to imagine -- but it's odd how your vision of the future changes once you stretch your mind and see what it might be like.

Would you start a business of your own?

Go back to school to upgrade your skills, or retrain for an entirely new career?

Tell your toxic boss where to stick it, and find a job with reasonable hours and nice people?

Spend a few years at home with your kids?

Join the Peace Corps?

Move to a town that you really love?

Save some money up, and retire early?

I should probably warn you: You may get good and angry once you start to take stock of the huge trade-offs you've made over the years just to hold onto your health insurance. You may be even more angry when you realize that nobody else in the industrialized world has had to make those choices.

I live in a country where nobody is tied to a job they hate, or forced to give up important life opportunities just to hang onto a health care plan that may or may not even come through for them when they need it. Nobody ever declares bankruptcy because they can't pay a medical bill, either: most Canadians find this as mind-blowing as Americans seem to find the "What would you do...?" question. Almost nobody dies because they can't get care (and when it does happen, it's a cause for national outrage).

Countries with universal coverage free up their citizens to take advantage of personal development opportunities that, in the long run, stimulate the economy and create a more skilled, traveled, educated, and fulfilled workforce. Americans, on the other hand, routinely stay chained to jobs they hate -- and are forced to pass up on chances to expand their horizons and their fortunes -- because they can't afford to jeopardize their health care coverage.

Our health care mess has reached a point where it jeopardizes not only our lives, but also our liberty, our property, and our ability to pursue happiness -- as well as the long-term strength of the economy as a whole.

We cannot abide more of the same. Let's make sure John McCain pays the ultimate political price for his indifference to this issue -- and that every other elected official hears, loud and clear, that health care is a right they ignore at their own peril.

In the meantime, indulge yourself in a little fantasy. What would you do with your life if you never had to worry about health care again? Tell us in the comments.

New U.S. Census Data: Same Reality

Alex Carter — Tue, 26 Aug 2008 14:27:42 -0400

Newly released data by the United States Census Bureau continues to show how much President George W. Bush has ravaged the American economic landscape.

Since 2000, median income has decreased 1 percent. That decline is magnified by the higher costs for energy, food and other items during that period; what families could buy for a dollar in 2000 now costs $1.25.

For some racial and ethnic groups, the burden is even heavier. In 2007, the median income for white people was $54,920; the median income for African Americans was more than $21,000 less. Median income for Hispanics was more than $16,000 less. Since 2000, white median income has decreased $12; for African Americans it has decreased $1,804, for Hispanics it has decreased $1,256, and for Asians it has decreased $1,030. Those are huge disparities that continue to lay bare the racial and ethnic inequality of America. There is no way around it.

Poverty follows a similar pattern. Since 2000, the number of people in poverty has increased by 5.7 million; the number of families in poverty has increased by 1.2 million, and the number of children in poverty has increased by 1.7 million. In 2007; 37.3 million people are suffering in poverty.

Almost 25 percent of African Americans and 22 percent of Hispanics lived in poverty in 2007. They do not want to be told the fundamentals of the economy are strong—or only have poverty addressed when a hurricane slams into poor and underrepresented communities and their faces, names, and stories become fodder for the 24-hour cable news channels. They want the American consciousness and political system to recognize their plight and put forth real policies to remedy this evil.

On health care, it's more of the same. Since 2000, the number of uninsured in America has increased by 7.3 million and those not covered equal 15.3 percent of the population. The percentages of Hispanics and African Americans without health care are well above the national average.

Nationally, the economy and the conditions for working people are worse since President Bush took office. Haven’t we learned that trickle-down economics does not work? We must revive our economy, take back our industries, and promote economic opportunity for all. Bush is definitely leaving us with a bang: In his last year; our economy is in a recession (even though the administration doesn’t want to admit it), families are poorer, people are losing their homes, energy costs are sky high and we continue to put billions and billions of dollars into the Iraq War—when we need strong investment here in the United States.

Be ready for the United States Census Bureau to release its 2008 data in August 2009. The data will continue to paint a very bleak picture: the poor will be poorer, the number of uninsured will be higher, and America will try to rebuild itself after eight years of economic terror. At that time, the progressive movement must be ready to reassure working-class families that the rescue—investments in our people, our common property and in the green energy that will power the fuure; economic policies that end the upward redistribution of wealth; the end of billions of dollars being sent to Iraq; and the empowerment of workers—is on its way.

This Week In "Insurance Company Rules": Forced To Raise Funds For Sick Friends

Bill Scher — Fri, 22 Aug 2008 10:59:33 -0400

Insurance Company Rules were in full effect this week, from New Orleans to Pennsylvania to The Hamptons, as communities rallied to raise funds for ill friends.

AmeriCorps volunteer Mark Smith has a hospital bill of more than $90,000, after relocating to help rebuild New Orleans, then getting shot in the abdomen and arm trying to stop a car theft. But the New Orleans Times-Picayune reports that his insurance company will only pay one-ninth of his medical expenses.

Despite the insurance company rules, the Friends In Need Foundation has organized a benefit this Sunday at the Mid-City Lanes Rock 'n' Bowl (one of the coolest places on earth, by the way) to help raise money for Mark's care. More information here.

The Chamersburg (PA) Public Opinion reports on Kathleen Angotti's struggles recovering from Lyme disease after her insurance company refused to pay for continuing treatment. She's become severely debilitated and wracked with symptoms. Her family is now soliciting donations to cover their costs. The Public Opinion reports:

After the diagnosis, Kathleen was treated with antibiotics, but they didn't help her condition. A doctor in Staten Island, N.Y., who specialized in Lyme disease, tried a different antibiotic. But that didn't help, either.

A different tack was tried -- antibiotics administered intravenously through a "pic" line inserted into her arm each day. Kathleen's symptoms improved with the treatment, but her insurance company refused to continue to pay for it.

The line was removed and her condition deteriorated.

A month after she was taken off the IV, her memory worsened and her pain returned.

At 24, Kathleen can't walk far and uses a wheelchair for longer distances.

She hasn't been able to ride a horse in more than a year, her mother said, adding that Kathleen sleeps 18 to 20 hours a day. She has developed other health problems, including lupus, and she has a small tumor on her pituitary gland.

The tumor causes her to have seizures. Plans have been made to have the tumor surgically removed later this month.

Recent tests revealed she still has Lyme disease and she's also been diagnosed with Rocky Mountain spotted fever, which is also contracted from a tick bite.

The family is concerned about funds to pay for their stay in Washington, D.C., while Kathleen undergoes surgery for removal of the tumor on her pituitary gland.

Gas cards or checks may be sent to Michele Angotti at 2821 Woodstock Road, Chambersburg 17201.

Mega-tony East Hampton, NY is losing family doctor Robert Semlear. Because of insurance company rules, he can't afford to stay. The East Hampton Star reports:

“I can’t afford to stay,” he said last Thursday. “It’s a comment on the state of medicine today, and I’m not the only one having problems financially.”

...

“Insurance companies are denying claims. We’re rejected constantly,” Dr. Semlear said. “We spend hours of staff time and our own time to get authorization for tests, consults that they say are not medically necessary. Then why did we go to medical school?”

Often he suspects something is wrong and wants to order a test, but the insurance company says no, he said. “It’s not fair to the patient or the doctor. The H.M.O. C.E.O.s are raking in millions and the rest of the system is falling apart.”

And that's how Insurance Company Rules work.

This Week In "Insurance Company Rules:" Joys of the Market Edition

Bill Scher — Fri, 15 Aug 2008 10:32:42 -0400

This week, the health insurance lobby continues it's "listening tour" by hosting a staged event in an undisclosed location where it could hear nothing it didn't want to hear, and didn't want you to hear. On the flip side, Health Care For America Now sought to amplify people's voices with the "Which Side Are You On?" call-in campaign, making it easy for people to contact their congressperson and find out if their representatives support the insurance companies, or us?

While the insurance companies seek to keep "Insurance Company Rules" in place, so they can do whatever they want, whenever they want, a glimpse of the conservative fantasy -- in which "Insurance Company Rules" would be in even greater force -- was revealed.

This Tuesday, The Wall Street Journal reported on the dangers individuals and small business owners are having trying to save money by purchasing insurance in the private market through group associations.

In short: with little watchdogging by our government, insurance companies are flat-out scamming consumers. WSJ reports:

The premiums can be cheaper and the benefits better than if you purchased coverage on your own because the associations' greater market clout may give them better negotiating power with insurers. But the cost and quality of coverage and the recourses available to consumers who feel they have been wronged can vary substantially, as insurance sold in this way tends to be more loosely regulated than individual health insurance or coverage offered by large employers.

Phony insurance is sometimes sold through real or bogus associations. From 2000 to 2002, 144 such scams left more than 200,000 policyholders with more than $252 million in medical bills, according to a 2004 report by congressional investigators. Illegal health plans flourish during periods of high premium increases. On Thursday the National Association of Insurance Commissioners issued an alert to consumers warning them about fraud.

Though one company actually was busted recently:

Last month HealthMarkets Inc.'s insurance subsidiaries -- MEGA Life and Health Insurance Co., Mid-West National Life Insurance Co. of Tennessee and Chesapeake Life Insurance Co. -- agreed to pay $20 million to settle violations found by regulators in 29 states relating to health coverage the companies sold to the self-employed through the National Association for the Self-Employed, Americans for Financial Security and the Alliance for Affordable Services. The companies' insurance agents didn't adequately explain what the policies covered, investigators found.

"Consumers thought they were buying major medical policies when in fact they were getting mini-meds," said Washington state Insurance Commissioner Mike Kreidler, an initiator of the three-year, multistate probe. (A so-called mini-med offers more limited coverage than a traditional plan.) "When they became hospitalized they discovered the plan covered virtually nothing," Mr. Kreidler said.

Of course, widely sharing risk helps lower costs and maximize bargaining power, which is why Health Care for America Now advocates the progressive vision of a public plan option -- helping save money for millions of Americans and for the overall health care system. At the same time, strong standards for private insurers would be put into place, along with an active government watchdog, or else insurance companies will continue game the system and drive up costs for everyone.

The conservative fantasy, now enshrined in Sen. John McCain's health care plan, is to end employer-based insurance and throw us all into an unregulated market, where "Insurance Company Rules" are the only rules.

Are these the rules you want controlling your health care?

Confront Rising Drug Prices

Isaiah J. Poole — Tue, 12 Aug 2008 12:26:32 -0400

The outlook for prescription drug costs, and for health care costs generally, continues to be ominous. Price increases of more than 100 percent for certain prescription drugs means it is more important than ever to give the Medicare program the power to bargain with drug companies for the best price, so that seniors and taxpayers don't bear an unfair burden because of these price hikes.

The latest Making Sense alert calls for getting this issue back on the front burner of the political debate, and it comes as researchers at the University of Minnesota report that prices of some drugs have gone up well over 100 percent, and in a few cases over 1,000 percent, in the past year.

Cost increases like these are already expected to have a ripple effect on private insurance premiums. An Aon Consulting report released this week projects that health care costs will be up 10.6 percent next year, increases that will be reflected in the health insurance premiums that people can expect to pay next year.

Even in the face of these cost increases, conservative lawmakers still oppose a commonsense policy shift that would simply allow Medicare to do what other government agencies that provide health care are able to, including the Department of Veterans Affairs, the Department of Defense, the Public Health Service and the Bureau of Prisons.

Because federal negotiation is prohibited, elderly Americans are being overcharged billions of dollars. Agencies that negotiate get much better drug prices than the private Part D insurance plans do. If Medicare was allowed to negotiate with manufacturers, the program would save approximately $90 billion a year, which could be passed along to the elderly in the form of lower costs or greater benefits.

From 2002 to 2007, prescription drug prices increased by 50 percent, more than 2½ times faster than inflation. Eight in 10 Americans think that the cost of prescription drugs is too high, and four in 10 report struggling to pay for medication prescribed by their doctors.

Sens. Amy Klobuchar, D-Minn., and Charles Schumer, D-N.Y., have asked the Government Accountability Office to investigate these drug price increases. That is an urgently needed first step. But while that investigation is happening, we should be asking candidates where they stand on allowing the Secretary of Health and Human Services to negotiate fair prescription drug prices or on creating a real Medicare prescription drug plan (one actually run by Medicare) that forces drug companies to compete to provide drugs at the lowest price.

Eighty-seven percent of Americans support “a proposal to allow Medicare to use its bargaining power to negotiate prescription drug prices with manufacturers.” Lowering Medicare drug costs – and reducing the influence of the drug industry—is critical to bringing skyrocketing prescription drug and health care costs under control for all Americans.

More detail on this topic is in our Making Sense alert on the Medicare prescription drug benefit.

This Week In "Insurance Company Rules"

Bill Scher — Fri, 08 Aug 2008 01:23:03 -0400

After the Health Care for America Now coalition unveiled it's brilliant "Insurance Company Rules" video (below) -- elegantly depicting how insurance companies regularly try to make up rules as they go along to deny people coverage and benefits -- I decided to start a new feature: This Week In Insurance Company Rules -- tracking the latest in insurance companies tricks and tactics to keep us unhealthy and uncovered.

This week, we start on a positive note: two stories where government actions denied attempts by insurance companies to lay down "insurance company rules."

The Syracuse Post-Standard reports that a single woman not only successfully challenged her insurance company in an appeal to the New York State insurance department, but her challenge forced the insurer to pay back 2,500 other women as well.

In 2004, an Ithaca woman filed a claim with her health insurance company for a $154 infertility treatment. The insurance company denied her claim, as they did for almost 2,500 other claims for the same treatment.

But the woman from Ithaca was sure the insurance company was wrong to deny her claim. She disputed their findings, but they continued to refuse. So she filed a complaint with the New York State Insurance Department.

Turns out she was right. Last month, the state Insurance Department fined the insurer, and ordered it to reimburse those 2,500 women who had been denied payment.

And in Tampa, the family of a teenage rape victim -- who is in long-term care recovering from a fractured forehead and several strokes from an attempted strangulation -- successfully prevented their insurance company from meddling with her treatment. From the Tampa Tribune:

The victim of a beating and rape three months ago at the Bloomingdale library, who remains in long-term rehabilitation, has gotten some help from the state.

The family of the 18-year-old woman received a letter from its insurance company saying she had to be moved from her current rehabilitation center to another. The family and the teen's doctors disputed the insurer's decision, and the state stepped in.

A Florida Department of Financial Services spokeswoman confirmed Friday that the department's consumer insurance advocate intervened in the case, ensuring that the long-term care will continue uninterrupted.

Jerri Franz, spokeswoman for the department, said the health insurance company that had covered medical costs for the teenager since the attack sent a letter to the family saying the teen would have to be moved to another facility for coverage to continue.

Franz said doctors and therapists disagreed with the plan to move the woman, and the state's advocate intervened.

"Her current doctors felt like it would interfere with her progress," Franz said, "and that she would not be able to overcome that. She would lose ground. So we made a call on family's behalf."

The state cannot force the insurance company to pay expenses, but the unnamed company agreed to allow the teenager to remain where she is, Franz said. "We are extremely pleased that she will be able to stay in her facility."

The Health Care for America Now principles -- which envision a system where private plans have to fairly compete with a public insurance option -- calls for "a watchdog role on all plans, to assure that risk is fairly spread among all health care payers and that insurers do not turn people away, raise rates or drop coverage based on a person’s health history or wrongly delay or deny care."

The above success stories show that government watchdogs are a critical part of the solution to end "insurance company rules" for good.

Prohibitive Prescriptions

Terrance Heath — Wed, 30 Jul 2008 12:06:59 -0400

You can tell a lot about a person by what in their medicine cabinet. A quick peek during a trip to the bathroom and the nosy neighbor could find out whose taking anti-depressants or birth control pills. Maybe someone is being treated for heart disease or bipolar disorder. Or perhaps someone is taking antibiotics for any number of conditions, from a sinus infection to an STD. Certain medicines, if you know what to look for, are a clear sign that someone is undergoing treatment for cancer or HIV.

Of course, most of keep to ourselves what medications we're taking. That's why they're behind the medicine cabinet door, and not lined up on the kitchen counter. Most of us don't go snooping in other people's medicine cabinets. (Do we?) And if we did, the worst we could do with the information is use it to spread gossip.

That is, unless we're in the business of looking into other people's medicine cabinets, or using the information obtained by those who are poking around in the nation's medicine cabinets..

You did know that there's a thriving business in buying and selling your prescription information, right? When you pick up your prescriptions, somebody besides you and your pharmacist knows what's in that bag.

An untold number of people have been rejected for medical coverage for a reason they never could have guessed: Insurance companies are using huge, commercially available prescription databases to screen out applicants based on their drug purchases.

Privacy and consumer advocates warn that the information can easily be misinterpreted or knowingly misused. At a minimum, the practice is adding another layer of anxiety to a marketplace that many consumers already find baffling. "It's making it harder to find insurance for people," says Jay Horowitz, an independent insurance agent in Overland Park, Kan.

Anxiety? You could call it that. For most of us, who have healthcare through our employers, there's not much to worry about. But for those who have to purchase individual insurance — and in this economy that could be any of us, since health insurance is usually attached to employment. So any of us could be in the same position as the Sheltons.

Walter Shelton, a 57-year-old safety consultant in the oil and gas industry, says he tried to explain that the medications weren't for serious ailments. The blood-pressure prescription related to a minor problem his wife, Paula, had with swelling of her ankles. The antidepressant was prescribed to help her sleep—a common "off-label" treatment doctors advise for some menopausal women. But drugs for depression and other mental health conditions are often red flags to insurers.

Despite his efforts to reassure Humana, the phone interview with the company representative "just went south," Walter recounts. He and his wife remain uninsured.

"I want to know what's in there if there's a black mark against us," Walter says. Paula, 51, adds: "We can't get health insurance because we're taking medications that were prescribed by our doctors. I don't think that's right."

A spokesman for Humana says the company uses "data regarding pharmacy history as part of our assessment process." But he adds that the insurer has a policy of not commenting on particular cases, such as the Sheltons' failed application.

Basically, needing health care — specifically needing particular medications — can disqualify you for health care coverage. For $15, insurance companies like Humana, Blue Cross, Aetna, or United Health Group can get a virtual peek into your medicine cabinet via a "pharmacy profile" provided by companies that gather information initially intended for to help doctors treat emergency room patients, but which has since been put to a more profitable use. After all, $15 to "identify high-risk, reduce costs, lower loss ratios, and increase revenue" is pretty cheap compared to the cost of covering those individuals.

And if it seems like, y'know, providing care isn't on that list of priorities, remember health insurance companies never really deny care. They merely deny coverage. You can always get care, provided you can pay for it. Of course, in an economy where rising health care costs are cutting into wages, almost none of us can handle the cost of serious illness or injury; or even the cost of getting old, for that matter. Look at the rise in bankruptcy among senior citizens, struggling to pay for their health care expenses. Even those of us who are insured are cutting back on medical care, squeezed between rising prescription costs, premiums, and even gas prices. American medical care might be the most expensive in the country, but most of us already aren't getting our money's worth.

And John McCain's health plan would make surea good many of us get even less -- something he probably knows right down to his $520 Ferragamo loafers, given that his own cancer history (with its attendant prescription history) would probably result a denial of coverage if he were almost anyone else besides Sen. John McCain. Somewhere in his 1,100 pages of medical records, some insurance industry employee would find something to "identify high-risk, reduce costs, lower loss ratios, and increase revenue."

But John McCain would never have to live with the realities of his own radical health plan, which would raise costs by dismantling the employer-based coverage system that insures 60 percent of us, putting us in the same position as the Shelton's; with a medicine cabinet full of prescriptions we need to keep us healthy, that could also get us denied health care coverage because they're instrumental in helping the insurance health industry "identify high-risk, reduce costs, lower loss ratios, and increase revenue."

So, again, what's in your medicine cabinet? Most likely, a prohibitive prescription or two.

[Photo via Merrick Brown.]

YouTube Ad Calls the Health Insurance Industry's Bluff

Anne Thompson — Tue, 29 Jul 2008 11:05:55 -0400

Campaign for America's Future, in conjunction with the new campaign Health Care for America Now, captures the health insurance industry failing to deliver on its promise to listen to citizens’ ideas about how to create “affordable, high quality health care for every American.” As part of the insurance industry’s new “listening tour” that launched last week, the insurance company front group Coalition for An American Health Care Solution has launched a hotline for individuals to share ideas about how to improve and expand the health care system. Yet, the hotline phone calls go straight to an answering machine, consistent with the industry’s woeful customer service record.

Your Health Care May Decide The 2008 Election

Robert Borosage — Wed, 23 Jul 2008 12:02:52 -0400

Now we're in the presidential campaign's silly season. The primaries are over; the conventions yet to come. Americans are tuning out politics and dialing in baseball and the Olympics, vacations and the price of gas.

Senator Barack Obama is traveling abroad, demonstrating that he really is a responsible driver. And Senator John McCain seems intent on running into every pothole in the road. This week, he published an op-ed in the New York Post slamming Obama for agreeing with the Iraqi Prime Minister that it is time to bring the troops home by 2010. Sure, McCain admitted, "Iraq's army will be equipped and trained by the middle of next year," but it will still need a lot of help. "The Iraqi air force, for one, still lags behind, and no modern army can operate without air cover." Particularly not against the fearsome al-Qaeda Air Force. And McCain didn't even mention the need to build Iraq a blue water navy. The $3 trillion Nobel Laureate Joe Stiglitz estimates we've squandered on the war — about a billion a day in direct and indirect costs — aren't nearly enough.

Americans will begin to tune into the election again around the conventions. And in the fall, they'll start to take a closer look at who the candidates are and what they believe. Issues matter less in this assessment than broad measures of the candidate's character and sense about whether he has a clue.

In this assessment, I suspect that one issue, seldom mentioned now, is going to matter a great deal by November. Iraq will be big no doubt; the economy bigger. But health care may just be the pothole that cracks up McCain's Straight Talk Express.

People worry a lot about affording health care. Workers accept lower wages with employers that offer health care. They hang onto lousy jobs to keep their health care. Most labor negotiations and disputes center largely on the costs of health care. On this issue, attention is paid over kitchen tables across the country.

So this fall, Americans will discover an inconvenient truth about John McCain. He wants you to lose your employer-based health care. He thinks you aren't sufficiently conscious about the cost of your health care, and you are using too much of it.

His plan is designed — with sugar and sticks — to push you to negotiate on your own with the friendly insurance companies. He'll give you a tax credit — $2,500 for an individual, $5,000 for a family — to help you pay the price. And he'll revoke the tax exemption for any health benefits your employer provides. Under his plan, those benefits will be taxed as income. McCain says this will reduce our health care expenditures. He might be right. His preferred option — health saving accounts — generally feature low monthly payments and very high deductibles. People tend to insure themselves against catastrophe and take a chance on routine health care.

On average, health savings accounts will work pretty well if you are young and healthy and lucky. But if you are sick, if you have suffered serious illnesses in the past, if you have what insurers call a "pre-existing condition," or if you are older and at higher risk, you're in trouble. For many, insurance won't be available at any price. That's why Elizabeth Edwards noted that, neither she nor McCain would be eligible for coverage since both have struggled with cancer. Many more will find adequate coverage unaffordable. Others will have to wrestle with choosing between paying to see a doctor or buying the weekly groceries. You'll be more "sensitive to price," but you might not think that a good thing.

McCain extols the benefits of private health insurance, but he's never had to negotiate with insurance companies. He's been on government-provided health care virtually his entire life. He was raised on military health care, as the son of an admiral. He then went to the Naval Academy and to the military. A year after leaving the military, he was headed to the Congress and enjoying the best government-supplied health care of all.

For the nine of 10 voters that have some kind of health insurance at work, the contrast will be clear. Obama will give them a choice between the health care they have and being able to buy into a public plan, something like Medicare. McCain will tax their employer based health care, and give them a break to negotiate their own deal with the insurance companies. At the same time, he will liberate the insurance companies from the state-based regulations that have provided some protection for consumers.

Invest in the Iraqi Air Force. Tax employer-based health care. Liberate the insurance companies. Leave you on your own on health care. If this keeps up, voters may decide it is time to take the keys away from the Straight Talk Express.

This column was first published in The Huffington Post.