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McCain vs. Obama: Who Has the Better Health Plan?

Monday September 22, 2008
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Which of the two health plans proposed by the presidential candidates will best provide Americans with the care they need? The answer depends upon each voter's individual health situation, say nursing and health policy analysts who have carefully examined both plans.

People who are young, in good health, and either are self-employed or contributing a large amount to employer-provided health coverage could save money under the plan of U.S. Sen. John McCain, R-Ariz. His plan features tax credits for individuals and families to buy health insurance, with any unused credits going into a health savings account.

Those who are older or who are in a low-to middle-income bracket, who have pre-existing health conditions or chronic illness, 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, 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, and this is a very classic Republican and Democratic difference, is what the scope of government involvement should be in solving the problem," she says.

McCain favors giving people money to buy their own plans and relying on the market to drive down costs rather than relying on insurance plans sponsored by employers, she says. Obama favors more insurance-industry regulation and the creation of a nationally financed insurance plan to cover those who can't get employer-sponsored insurance.

McCain's vision

The McCain plan, which can be found at www.JohnMcCain.com, proposes tax credits — $2,500 for individuals and $5,000 for families — that would be paid directly to an insurer chosen by each recipient, including employer-sponsored insurers. 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.

O'Grady says McCain wants to encourage people who do not think they need insurance to buy it by giving them money to do so. As more people buy private insurance, McCain believes competition among insurance companies will increase and prices will come down.

It is possible some healthy, young people will save money by switching to less expensive private plans, says Judith K. Leavitt, RN, MEd, FAAN, a health policy consultant, but she also fears employer-sponsored plans would be left with the sickest and most expensive workers, which could drive up costs of those plans.

McCain plans to end tax breaks to employers who offer insurance, increasing the likelihood that some companies would stop offering insurance to their workers, she says.

"If anything, McCain's plan is much more radical," she says. "It changes the way most people get health insurance by moving away from employer-sponsored health plans and going to private, individual coverage."

McCain's tax credits will not cover the cost of health insurance for many families, nurse analysts say. Melanie Balestra, RN, NP, JD, an attorney in California and Arizona and a pediatric nurse practitioner at Laguna Beach Community Clinic in Southern California, says she pays about $800 a month for coverage. "Unless someone does something with the insurance companies, there's no way" the tax credits will cover insurance costs, she says.

O'Grady says she has not seen much evidence that people want to choose their own insurance plans. The myriad private plans with varying requirements, deductibles, and co-pays is confusing even to well-educated healthcare workers, let alone someone working two jobs and caring for a family.

"It's a lot to manage," she says. "People want better care, not more insurance choices."

Health policy analysts also have concerns about how well McCain's plan will extend coverage to everyone, especially 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. "I think it's going to be a much harder battle" than a national plan, she says.

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 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 to cover the conditions that caused people to apply in the first place.

"Where is the money going to come from to help cover these high-risk people?" Leavitt asks. "The tax credit is a start, but it's not going to begin to cover the costs."

Nursing policy analysts like 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.

"That's where we're probably most in-sync with Sen. McCain's plan," says Cynthia Haney, JD, senior policy fellow at the ANA.

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 based on one offered to federal government employees as an alternative to private plans. Obama also would 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 Haney. The ANA, which endorsed U.S. Sen. Hillary Clinton, D-NY, in the primary elections, recently endorsed Obama.

In a Sept. 12 press release, ANA President Rebecca M. Patton, RN, MSN, CNOR, said, "As President, Barack Obama will bring real change to our health care system. Nurses are consistently voted the most trusted profession by the American people, and we, as a profession, trust that Barack Obama will see that affordable quality health care is made available to everyone."

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. Obama would cover "all Americans who want to be covered" with a national plan but still offer choices for those who want to keep their plans or buy their own insurance, she says.

But some nurses wonder how the country will pay for such a plan, especially given the current state of the economy.

"Obama's promising everything on earth, but he doesn't say where the money's coming from," says Balestra.

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 and retaining the estate tax at its 2009 level. Obama says he'll further reduce costs by investing in computerized medical records, cutting administrative spending in the insurance industry, and improving prevention and chronic disease management programs — practices McCain also endorses to reduce healthcare costs to help pay for his health plan.

But Leavitt says although these efforts may save money in the long run, they require upfront investments, and the cost advantages may not show for some years. Prevention programs may improve a patient's quality of life, but no hard evidence exists to show they provide immediate and guaranteed cost savings. An article in the Feb. 14, issue of New England Journal of Medicine, "Does Preventive Care Save Money? Health Economics and the Presidential Candidates," says just that.

"Sweeping statements about the cost-saving potential of prevention, however, are overreaching," the authors write. "Studies have concluded that preventing illness can in some cases save money but in other cases can add to healthcare costs. Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question."

Some nurses say the Obama plan is a step in the right direction, but 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.

But Obama's plan does focus on getting everyone some sort of health coverage, O'Grady says. "I think the healthcare problem of our time is access and the uninsured, and Obama addresses these," O'Grady says. "You can't have quality without access."

Both candidates promise to bring health costs down and help pay for their plans by promoting increased competition among drug and health insurance companies. Both support mental health parity and the need to make healthcare costs transparent. 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 say, nurses need to add their voices to the debate, by working with their state and local legislators. "If you do not make health reform one of your top priorities, you are not going to capture the opportunity right now to make these big changes," Haney says. "Now there's momentum and we must take advantage of this window."

Need for Nurses

McCain’s Camp Speaks Out

McCain’s plan will address the nursing shortage by —

• Encouraging more public and private sector scholarship programs and loan repayment incentives
• Ensuring that the workforce of the 21st century is diverse and equipped to provide culturally competent care
• Ensuring appropriate funding for programs such as the National Health Service Corps and HRSA Health Professions Programs to increase participation in areas of critical shortage, especially in rural areas

Obama's Camp Speaks Out

Obama’s plan will address the nursing shortage by —

• Supporting minimum nursing staff ratios and limitations on overtime
• Reauthorizing Title VIII training programs, with financial incentives, including scholarships and loan repayment
• Expanding health system redesign, especially initiatives for multidisciplinary care and challenging work environments, such as EDs
• Supporting adoption of health information technology



Cathryn Domrose is a staff writer for Nursing Spectrum/NurseWeek magazines. To comment, e-mail editorNTL@gannetthg.com.