This is the fifth in a weekly series of stories leading up to the presidential election examining the candidates' positions on various issues that affect northeast Indiana residents.
While 46 million uninsured Americans worry about what to do if they get seriously ill, health care providers, employers and Americans in general stand at the bedside of the ailing health care system, bandaging wounds, checking the pulse, exhausted from doing CPR.
“The health care system isn't just sick. It's critically ill,” said Dr. Barney Maynard. The Evansville physician just completed his eighth year on the American Medical Association's Legislative Council, which reviews all health care legislation for the 250,000-member organization.
Says Republican presidential candidate Sen. John McCain: “Americans deserve leadership for real health care reform that provides access to high-quality medical care and ends spiraling costs. But the road to reform does not lead through Washington and a hugely expensive, bureaucratic, government-controlled system.”
Says Democrat presidential candidate Sen. Barack Obama: “Increasingly our health care system gets in the way of (health care providers') sound medical judgment. Increasing, uncompensated care loads, administrative rules and insurers' coverage decisions inappropriately influence the practice of medicine. Washington sends dictates but no help.”
Their comments, published in Thursday's New England Journal of Medicine (NEJM), echo the moans heard across the country. A year ago, health care reform was the No.1 presidential platform issue. Although it's been overshadowed in recent weeks by the economy, the Kaiser Family Foundation says it remains the No.2 issue on the minds of American voters.
What is the diagnosis? Where is the cure? Who will perform rehab? And who will pay the bill?
Employer-based insurance has been the cornerstone of America's health system for decades. But considering 80 percent of the uninsured have jobs - they may work part time, are self-employed, have no group insurance option or cannot afford it - cracks in the cornerstone have turned to crevasses that cannot be bridged by more and more people.
“Fifteen years ago, the AMA's (American Medical Association's) mandate was employer-based health care. That has evolved over the last decade way away from that,” said Maynard. “Trying to keep a private practice, listening to patients every day in the office and at the hospital - something's got to give.”
Loss of employer-based insurance for 33-year-old Gabrielle Kenna, a Fort Wayne school social worker, has torn her lifeline to health into fragile threads. When her full-time job was cut to part time, she lost benefits that covered the $67,000-a-year intravenous drug Remicade she needs to ease debilitating symptoms of rheumatoid arthritis.
When she was insured, the medication cost $12,000 annually under the rate negotiated by her insurance company. She and her family are now scraping together the $570 monthly COBRA premium. COBRA is the federal measure that allows employees to pay the full cost of insurance for a time after they lose employer-based coverage.
But COBRA will end. “Then what?” Edith Kenna, Gabrielle's mother, said. “Without this medicine, my daughter's in a wheelchair.” She advocates for a single-payer, Medicare-for-all type system.
Neither McCain nor Obama seeks a single-payer system or coverage for everyone, although Obama would mandate all children be insured. Both candidates' health plans include employer-based insurance as an option. Among other similarities of the two plans: increased funding for and use of health care information technology; attaching quality to provider reimbursement; and more emphasis on prevention and wellness.
But their plans' divergence goes to the core of the question moderator Tom Brokaw asked during last week's debate in Nashville, Tenn.: Is health care a privilege, a right or a responsibility? The candidates' answers reflect fundamental differences.
McCain said health care is a responsibility. He advocates for a system less dependent on employer-based insurance and that puts greater decision-making on employees. Employers would no longer receive tax breaks on their premium contributions. Individuals and families would receive a tax credit of $2,500 and $5,000, respectively, that must be used to buy insurance through their employer or a private plan in a wide-open market that allows consumers to shop for plans across state lines. More options and greater competition will drive down costs, McCain says. The tax credit would be taxable income.
“An essential benefit of this reform is that it will help to change the whole dynamic of the current health care system by putting individuals and families back in charge and forcing insurance companies to respond with better service at lower cost,” McCain said in written comments to NEJM.
Many policy analysts are concerned that McCain's plan will disincentivize employers to offer insurance.
“Under the McCain plan, employers would see the removal of the tax treatment of employer payments for coverage as a green light to stop paying for coverage, since it will be the employees who will pay the premiums and get the tax credit,” said Harvard economist Katherine Swartz during a late September roundtable discussion sponsored by the health policy journal Health Affairs. Other analysts say premium costs will rise faster than the tax credits.
McCain plans to “fund the tax credits, in part, with savings from Medicare and Medicaid,” through elimination of fraud and program improvement, his senior policy adviser Douglas Holtz-Eakin told The Wall Street Journal in an article published Sept. 28.
Obama's plan moves closer to universal coverage in that his mixture of private/public options would be accessible to everyone. Participants could remain on their employer's plan or choose a new national health plan that would provide “the same coverage that is offered to members of Congress and their families,” Obama said in NEJM.
Small businesses, the self-employed or others without employer-based options or who do not qualify for Medicaid would have an option of the national plan or a private plan approved by a National Health Insurance Exchange, with federal subsidies helping pay premiums. Medicaid and State Children's Health Insurance (SCHIP) eligibility would be expanded.
Critics say the additional subsidies, along with expansion of Medicaid and SCHIP, plus heavy regulation on the insurance industry, will drive up the cost of insurance and increase taxes. The vagueness of how much taxes will go up is troubling to some.
“It is the spending gap, the 2 1/2 percentage-point growth faster than the rest of the economy that we have in health care, have had for the last 45 years, combined with the aging baby boomers, that we can't sustain,” said Gail Wilensky, a a senior fellow at the nonprofit Project HOPE, which provides health services around the world. Her comments were made at the roundtable.
Obama's funding would come from ending tax cuts for people with incomes over $250,000 and from eliminating the higher subsidies paid to Medicare Advantage plans. He would also negotiate Medicare drug costs. Both candidates also count on savings by reducing chronic diseases through education toward healthier lifestyles and a greater focus on prevention.
But Dr. Deborah McMahan, Allen County commissioner of health, says assumptions can lead to flawed decisions.
“People know the right things to do - exercise, eat right, don't smoke.” Although she champions wellness and prevention programs, she said, “People don't want to pay for health care when they're sick, let alone when they're well. People don't value health. What they value is the absence of disease.”