Which Plan for America?
Monday September 8, 2008
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People who are young, in good health, and are either self-employed or contributing a large amount of money to employer-provided health coverage could save money under the plan of U.S. Sen. John McCain, R-Ariz., which features tax credits for individuals and families to buy health insurance, with anything left over going into a health savings account.
Those who are older or in a low-to-middle-income bracket, who have pre-existing health conditions or chronic illnesses, and who don't have employer-sponsored health insurance or are under-insured are more likely to get health coverage they can afford from the plan of U.S. Sen. Barack Obama, D-Ill., which offers subsidies to the poor, insurance reform to guarantee affordable coverage, and a new federal health plan.
The two candidates identify many of the same problems with the country's health system, including escalating costs and a growing number of uninsured people, says Eileen T. O'Grady, RN, PhD, NP, policy editor of the American Journal for Nurse Practitioners.
"Where they differ is about what the scope of government involvement should be in solving the problem," she says.
McCain favors giving people money to buy their own health plans, rather than those sponsored by an employer, and relying on the market to drive down costs, O'Grady says. Obama favors insurance-industry regulation and the creation of a nationally financed insurance plan to cover individuals who can't get employer-sponsored insurance.
Obama's vision
Obama's plan, outlined on his Web site (www.barackobama.com), includes mandatory insurance coverage for all children, subsidies for middle-income families who can't afford insurance, and a national insurance plan similar to the plan offered to federal government employees. Obama also would attempt to create a national insurance exchange to help people buy private insurance and require insurance companies to cover people with pre-existing or chronic conditions.
Obama's plan is "most consistent with the American Nurses Association's policy for healthcare reform" because it "guarantees high-quality affordable healthcare for all," says Cynthia Haney, JD, senior policy fellow at the ANA. The ANA endorsed U.S. Sen. Hillary Clinton, D-N.Y., in the primary elections but has yet to endorse a presidential candidate.
Obama's plan "is a comprehensive, well-researched document, whether you agree with it or not," says Linda Tarr-Whelan, MS, FAAN, a Demos Senior Fellow on Women's Leadership who has served in the Clinton and Carter administrations. But some nurses wonder how the country will pay for it, especially given the current state of the economy.
Obama's health advisers estimate his plan will cost $50 billion to $65 billion. They propose paying for it by letting tax cuts expire for those making more than $250,000 a year, but this accounts for only about half of the estimated costs. Obama says he will make up the rest by investing in computerized medical records, reducing administrative costs in the insurance industry, and improving prevention and chronic disease management programs — practices McCain also endorses to reduce healthcare costs and help pay for his health plan.
But Judith K. Leavitt, RN, MEd, FAAN, a health policy consultant and the author of "Policy and Politics in Nursing and Health Care," says these steps require upfront investments and the cost advantages may not be gained for several years. And no hard evidence exists to show prevention programs provide immediate and guaranteed cost savings.
Some nurses say the Obama plan is a step in the right direction but that it doesn't go far enough. A number of healthcare organizations, including the ANA, have called for a single-payer government-sponsored system, similar to those in most European countries, Japan, and Canada.
McCain's vision
The McCain plan, which can be found at www.johnmccain.com, proposes tax credits of $2,500 for individuals and $5,000 for families that would be paid directly to an insurer chosen by each recipient, including employer-sponsored coverage. McCain says he will work with state governors to create guaranteed access plans, similar to the high-risk pools some states now have, to cover those with pre-existing conditions at affordable rates.
"McCain wants to return control [of buying health insurance] to patients," O'Grady says. He wants to encourage people who don't think they need insurance to buy it. As more people buy private insurance, McCain believes competition among insurance companies will increase and prices will come down.
Leavitt says she fears employer-sponsored plans would be left with the sickest and most expensive workers, which could drive up costs of employer-sponsored plans. McCain plans to end tax breaks to employers who offer insurance, increasing the likelihood that many companies would eventually stop offering insurance to their workers, she says.
Health policy analysts also have concerns about how well McCain's plan will cover everyone, including those with pre-existing and chronic conditions.
McCain says he will work with state governors to create nonprofit plans to cover people denied insurance, says O'Grady, but the details of these plans are vague. High-risk pools now cover only 207,000 of the country's 47 million uninsured people, according to the National Association of State Comprehensive Health Insurance Plans. Premiums can be as much as twice the standard rate in some states but do not cover health costs, leaving states to cover about 40% of the claims. In some states, this has led to enrollment restrictions and waiting periods of up to a year to cover the conditions that caused people to apply in the first place.
Nursing policy analysts liked McCain's proposal to expand the use of nurse practitioners in retail clinics to improve access to healthcare, and they hope this means he will work to expand the scope of practice for nurse practitioners.
Both candidates promise to bring health costs down and help pay for their plans by promoting increased competition among drug and health insurance companies and by investing in information technology, coordinated care and disease management, wellness and prevention programs, and health education starting at school levels. Both support mental health parity, a strong public health system, and making healthcare costs transparent.
The real work on healthcare will be done in the months after the elections, with Congress. How much reform will happen depends on both the leadership in the White House and the congressional political will to do it, nurse analysts say. Now more than ever, they add, nurses need to add their voices to the debate, particularly by working with their state and local legislators.
Cathryn Domsrose is a staff writer for Nursing Spectrum/ NurseWeek magazines. To comment, e-mail editorNTL@gannetthg.com.
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