March 13, 2010

Both candidates propose bold changeMAINE/NEW ENGLAND


— Fourth in a series

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Jack Milton/Staff Photographer: Friday, October 3, 2008: Jessica Moore, of Portland, who works part-time, and attends the Bangor Theological Seminary, has no health insurance. She pays for care out of her pocket and worries about what would happen if she got a serious illness.

Jack Milton

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Staff Writer

When Jessica Moore owned her own small business in Portland, the insurance she carried had such a high deductible she found it almost impossible to use. Now she is back in school, getting her master's degree and working part time, and has no insurance at all.

Moore, 37, gets by like many of the nation's uninsured. She spends a few hundred dollars each year out of pocket for things like eye and dental exams, and checkups with her gynecologist. She goes to the University of New England's Dental Hygiene Clinic to get her teeth cleaned for about $30, compared with the nearly $100 it might cost at a local dentist's office.

Moore, a Portland resident, doesn't have any major health problems right now, but frets about what might happen in the future.

''I worry about it, but part of me thinks you can't get blood from a stone,'' she said. ''I do worry about an accident or a chronic illness.''

Moore sees health care as one of the major issues in the presidential campaign. But she is tired of listening to candidates pitch ideas that go nowhere, in speeches ''still fraught with a lot of backhanded language and soft-soaping a lot of stuff.''

''This is the kind of subject that needs a strong approach,'' Moore said.

Consumers like Moore may be happy to hear there are clear choices in the presidential candidates' approaches to health care, and both the plans by Democratic nominee Barack Obama and Republican nominee John McCain include some bold strokes.

''The Obama plan is really an effort to cover most of the uninsured and to make insurance universally accessible, and it's sort of bold in that sense,'' says Jonathan Oberlander, a political scientist at the University of North Carolina who specializes in health policy. ''The McCain plan, by most outside analysts' thinking, is not going to cover most of the uninsured and won't affect our uninsured rate very much, but is very bold in terms of trying to change the insurance market.''

There are key philosophical differences in each plan that mirror basic philosophies of the Republican and Democratic parties. McCain's plan, for instance, emphasizes deregulation and competition to make insurance more affordable. His plan would move Americans away from employer-sponsored insurance by giving them tax credits they can use to shop, nationwide, for the insurance that best suits their families.

''The idea there is that if you deregulate so that all the insurance companies are playing on a level playing field, they're going to develop lower-cost products that will be more attractive to people who want to purchase insurance in the individual market,'' said Jennifer Tolbert, principal policy analyst with the Kaiser Family Foundation. ''Right now, it's up to the states to regulate those markets, so you have vastly different regulatory structures across the states.''

Obama's plan builds on the employer-based system and existing public programs. Government would play a larger role in his plan through refundable tax credits for small businesses and the creation of a national insurance plan to cover people who can't get coverage now. Adults would not be required to have health insurance, but all children would be covered.

Employers would have to play or pay -- those who choose not to offer health benefits would be required to contribute to the cost of the new public health insurance program.

''He would prohibit insurers from denying people coverage based on health status,'' Tolbert said, ''and would also prohibit insurers from charging people higher premiums based on their health status.''

Those are the broad strokes. But what about the details?

If you get health insurance through your employer, a McCain administration would tax those benefits, ''which is something that I think is not widely understood'' by the public, Oberlander said.

McCain would replace the current tax exclusion for employer contributions to health plans with refundable tax credits for everyone -- $2,500 for individuals or $5,000 for families. For people who have insurance through their employers, the tax credit would offset the cost of paying taxes on their health benefits. Or workers could use the money to offset the cost of buying whatever health plan they want in the individual market.

But would employers continue to offer health care coverage without the tax advantages?

''What a lot of health economists worry about is that the McCain plan would result in a lot of smaller and medium-sized employers dropping coverage,'' said John Holahan, director of the Health Policy Center at the Urban Institute in Washington, D.C., who co-authored a detailed analysis of each candidate's plan.

Another issue is just how far the tax credits would go in helping Americans pay for their own insurance. The average cost of a family plan these days is more than $12,680, according to the 2008 employer health benefits survey conducted by the Kaiser Family Foundation and the Health Research & Educational Trust, so low- or middle-income workers may have more trouble making up the difference out of their own pockets, analysts say.

Analysts also point out that McCain's tax credits will lose value over time as medical costs rise.

''Here's the thing,'' Oberlander said. ''Over time, health insurance costs are going to go up at a very significant rate, but the credit is not indexed to medical inflation -- it is indexed to general inflation -- so it's a hidden tax increase. The value of that credit erodes over time. It would not make up, for as many people, the difference in terms of what they have to pay for health insurance costs.''

But the tax credits are still better than what the uninsured have at the moment, Tolbert said.

''McCain would argue that for people who are having to purchase coverage on their own now, who aren't offered coverage by their employer and aren't eligible for existing public programs, they're getting no help at all,'' she said.

Deregulation of health care would benefit young, healthy Americans the most. Analysts say older, sicker people would have a harder time finding someone to cover them under McCain's plan, an issue McCain would address by creating high-risk pools to keep down costs.

Obama's National Health Insurance Exchange would automatically cover people with pre-existing conditions, and income-based subsidies would make the insurance more affordable.

''Now, we've seen this model work at the state level in Massachusetts with the Commonwealth Connector,'' Tolbert said, ''and because it's somewhat modeled on the federal employee health benefit program, there clearly is some experience on which to create this new mechanism. But it is kind of a new concept, and so it's somewhat unclear how it would function at a national level.''

Obama's plan would still leave about 6 percent of the non-elderly population uninsured, according to Holahan's analysis, and businesses may object to the employer mandate.

How will Obama pay for everything he wants to do? Obama's reforms are expected to cost $50 billion to $65 billion, which he says would come, in part, from rollbacks in the Bush tax cuts for people making more than $250,000 a year. Oberlander said the federal government already assumes those cuts will expire after 2010, ''so you don't get any extra money in terms of the Congressional budget rules by letting them expire.''

''That means he's got to get the money elsewhere,'' Oberlander said, ''and that is a non-trivial matter.''

Joe Ditre, executive director of Consumers for Affordable Health Care in Augusta, said he doesn't think either candidates' plan does enough to try to rein in costs.

''Neither of the plans says let's go to a system of payment for services that would make greater consistency among payers,'' he said. ''One of the problems that we have is when you have multiple payers, whether they're private or public -- Medicare, Medicaid or the multiplicity of private insurance -- they're all paying at different rates, and they all have different administrative costs. I believe that there is a need for payment reform in order to, over time, make either of these plans sustainable.''

The question of money looms larger now, with financial firms in turmoil and experts predicting that the country is in for a rough ride economically for the next few years. Will health care end up a dead issue during the next president's tenure, or will it be resuscitated as health care costs continue to increase?

A September poll by the Kaiser Family Foundation found that 30 percent of Americans report having serious problems paying for health care and health insurance, an increase of 6 percentage points over the previous month. And that was before the financial meltdown.

''When you dig deeper, as the Kaiser Family Foundation did, you find that one of the top concerns people have with respect to the economy is the unaffordability of health care,'' said Ron Pollack, executive director of the nonpartisan group Families USA. ''So I think it is an area that is going to get priority attention.''

Other analysts are less optimistic. Oberlander believes the chances that anything substantial will get done are low, but is keeping a wait-and-see attitude.

''I used to go around the country giving a talk called 'Why we'll never enact national health insurance (and why the Red Sox will never win the World Series)''' Oberlander said. ''And the lesson I learned in 2004 is, just because something hasn't happened before, and just because you've had decades and decades of failure, just because the odds are against you, it doesn't mean that it can't happen.''

Staff Writer Meredith Goad can be contacted at 791-6332 or at:

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John McCain
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John McCain


Barack Obama
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Barack Obama



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