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Health care tough to dodge

New president must face issue, last tackled in ’93

No matter who wins the White House and control of Congress in November, one aspect of 2009 could have a familiar feel.

The winner, along with members of his Cabinet and Congress, will quickly face the twin problems of the nation’s health care: rising costs and declining numbers of people insured.

The system is complicated. Solutions vary widely. Billions of dollars are at stake, so the lobbying will be intense.

Next year could be a rerun of 1993, the last time the United States seriously tried to tackle its health care problems. Tried, and failed.

An effort led by then-first lady Hillary Clinton and eventually dubbed “Hillary Care” fell apart, in part because critics successfully argued there was too much government involvement being proposed. Since that time, for all the talk about the need to reform the system, little has been done, health care experts said.

“Everyone got gun shy,” said Dr. Cecil Wilson, a Winter Park, Fla., internist and board member of the American Medical Association.

The problems haven’t gone away. If anything, the twin stresses of rising costs and lack of insurance have only grown, Wilson said. At any given time, the AMA estimates more than 45 million Americans are without insurance, and about three-quarters go without coverage for more than a year. Over the course of the year, as many as 80 million Americans will be without health insurance for at least a month.

“Voters have continually rated health care as one of the top issues,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, an insurance industry trade association. While it may be eclipsed this fall by economic concerns, Zirkelbach and others contend health care is such a big part of the economy that the two are intertwined.

A voter’s perspective on health care problems varies with his or her individual circumstances, said Sue Blevins , of the Institute for Health Freedom.

A voter who has a job with health insurance, and is relatively happy with the plan, wants to know how costs and services would be affected if the federal government changes the system, Blevins said. Business owners who don’t currently offer health insurance want to know how much a plan would cost and whether they’d be able to find one if the government requires coverage. A person with so little income that he or she needs to sign up for a government program wants to know what services would be covered. A tax break may not matter, because that voter has little, if any, tax liability.

The institute believes the most important issues for any of these voters are the Three C’s, Blevins said: choice, the contract and confidentiality.

The institute is against a “one size fits all” system, run by the government or otherwise, she said.

Neither Barack Obama nor John McCain is proposing a government-run “single payer” system, said Joel White, of the Coalition for Affordable Health Care. While they both recognize the problems of cost and access, the two major-party candidates are suggesting very different solutions, he added.

McCain has a proposal that offers tax credits to help workers buy insurance if their company doesn’t offer a plan. With that money, a single person or a family could shop for health insurance, not just in the state of residence but anywhere in the country.

The McCain plan also makes a significant change in about 60 years of tax policy by treating an employee’s health insurance as taxable income rather than an untaxed benefit.

Obama’s proposal sets up a federal insurance pool for companies that don’t offer health coverage, with tax incentives for a company to join the pool. Companies could decline, and their employees could buy individual plans, but large companies would pay a new tax through a system known as “play or pay.”

Each candidate has significant details in his plan, such as the amount of the tax credit or the payroll tax, but health care experts caution about getting too wrapped up in the numbers; they’re likely to change as Congress debates the issue. So is a list of services that would be covered by a basic plan, whether consumers can buy extra coverage – and at what cost.

Despite their differences on how to attack the overall issues of access and cost, McCain and Obama agree on some of the other aspects of health care reform, White and others said.

Both want to expand computer technology for keeping and transferring medical records. While many believe that will bring down administrative costs, not everyone thinks that’s a good idea. Blevins, of the Institute for Health Freedom, said there are privacy concerns because computer records can be hacked.

Some people may be willing to give up a level of privacy to cut costs, but those who want to protect their privacy should be allowed to pay more for health care that keeps their records on paper, she said.

Both candidates would try to reduce drug costs by allowing some pharmaceuticals to be imported from other countries, where some drugs are cheaper even if they originated in the United States.

The candidates also agree on putting more emphasis on “coordinated care” care, a term that describes a system where patients with more than one serious medical condition have plans with one doctor overseeing the different types of treatments and prescriptions from specialists. These patients often require the most resources to treat and tend to get sick quickly when a problem develops. For this and other aspects of their health care plans, however, “there aren’t a lot of details or specifics,” White said.

Health insurance could become much more of a consumer item, where individuals have more say in the type of coverage they buy, and where they buy it. For some, that will be daunting, the AMA’s Wilson acknowledged. Think of the initial confusion when the federal government introduced Plan D, the prescription drug coverage options for Medicare recipients.

But most consumers will adjust and learn to pick and choose, just as they do when shopping for car insurance, he said. Neither the health care industry nor politicians should underestimate the American public.

Contact Jim Camden at (509) 459-5461 or


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