Campaign Issues 101: Health Care

Today, we are kicking off "Campaign Issues 101," a series where we dissect key ideas in the presidential campaigns and see how they stack up next to each other. First up: health care. For insight, Farai Chideya talks with Paul Ginsberg, president of the Center for Studying Health System Change.

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FARAI CHIDEYA host:

From NPR News, this is NEW & NOTES. I'm Farai Chideya. Speeches, rhetoric and smear campaigns, just another day in election paradise. But beyond all that lie the issues. What do you want from government and how do the candidates plan to help the nation? Today, we're going to begin the first installment of Campaign Issues 101, where we pick apart key ideas in the campaigns of the presidential candidates and see how they stack up next to each other.

Today, we tackle health care. And with me here to help is Paul Ginsberg. He's president of the Center for Studying Health Care System Change. Paul, welcome.

Mr. PAUL GINSBERG (President, Center for Studying Heath Care System Change): Thank you.

CHIDEYA: So without going into the candidates just yet, what is it that Americans want from the heath care system? There's been a lot of critics and a lot of proposals. What do you get a sense of in terms of trends of what Americans want to see in the federal government and health care?

Mr. GINSBERG: I think there are two things that are really motivating voters this time around. A lot of people are worried about their being about to afford health insurance in the future, because costs are rising so fast, and a lot faster than their incomes. And so this has brought an issue that was last really strong in the early 1990s about expanding health insurance coverage.

But it's really very linked with the cost issue, because I think many people recognize that it's rising costs that are causing the problem. So unless the candidates have a solution to rising costs, some of their terrific ideas for expanding coverage may fall short.

CHIDEYA: Let's focus in on families. If you were - I won't say the typical, because it is not the typical family - but the kind of prototypical family with mother, father, two kids, what kind of choices should you be looking at? Or what kind of decision making process should you be looking at when you evaluate the health care plans that are coming from the politicians?

Mr. GINSBERG: Well, I mean as far their concepts.

CHIDEYA: Exactly.

Mr. GINSBERG: Yeah, I think what you should be evaluating is, you know, are they offering something that'll ensure that you can buy coverage. And there really are two aspects to that. If you have low income, you know, then the issue is, you know, will you be covered by their subsidies or will you be eligible for public insurance under their plan? But if you don't have a connection with employer-based coverage, I think you are very concerned about reforms to the individual health insurance market.

In other words, even if you get a subsidy, you don't want to go into a market where they might say, sorry, you have a preexisting condition. We won't cover that, or we won't sell you coverage at all because your medical history is unfavorable. So in a sense, it's the, not only being subsidized, but it's the ability to buy coverage at a reasonable price. And, you know, ironically, the Republican candidates tend to stress use of the individual insurance market more than the Democratic candidates.

You know, they, you know, they're not expanding public programs. They are offering tax subsidies to use the individual insurance market, but they haven't, you know, followed through with a plan about how are they going to make the individual market a less expensive and more reliable and viable source for buying coverage. And the Democrats have actually put forward proposals to set up insurance exchanges or something like the Federal Employees Health Benefits Program to really provide a working market where people can have confidence that if they can afford a reasonable cost for insurance, that they won't be excluded from that marketplace.

CHIDEYA: Is there a difference in what families with children might look for, as opposed to families without children or individuals without children? And, of course, you know, one thing I should mention is that everyone votes their self-interest in a strict way. If someone says, well, I'm single, but I really care about what happens to other people's children, that may also affect their decision making. But let's say that you were being completely focused on your best deal that you could get from politicians. If you're someone with no kids or no kids under the age of 18, what might you be looking for?

Mr. GINSBERG: You know, I'm not sure that it makes much difference whether you have children or not, except to the extent that, you know, we've had a history of policy which has made public coverage more readily available to children than it has to adults. So, you know, the income limits for the SCHIP program are higher than the income limits for Medicaid.

And all children from low income families are eligible for that, whereas, you know, adults without children are not eligible for Medicaid in many states. Actually, some of the Democratic proposals might actually do more for low income childless adults because it would give them the eligibility for public programs that they haven't had so far.

There's actually more of a consensus throughout the nation about the virtues of ensuring coverage for children, and as a result, you know, a much higher percentage of children have coverage today than is the case for adults.

CHIDEYA: What about the issue of a business owner? There are some differences in how the Republicans and Democrats approach business' obligations towards individuals and also the tax credits that businesses might be able to get. If you are a business owner, what kind of questions should you be asking?

Mr. GINSBERG: Well, that would depend on whether I offer insurance or not. And let's start with, say, the small business that does not offer insurance, and there are probably some things about the Democratic plans that they won't be happy about because, you know, there is a requirement to make coverage available and something to pay if you don't.

Now, you know, saying that, that's part of the Massachusetts program, where the amount that employers pay is really pretty limited and is not slated to become very large. In contrast, Governor Schwarzenegger's plan in California which, you know, was defeated in committee and the State Senate, I guess a month ago, that had a much larger burden for employers.

Now, moving on to, say, if you're a large employer and, you know, virtually all large employers provide coverage in the United States today and have for a long time, they'll be watching very carefully at the changes in the text treatments of employer-provided health insurance that are being proposed, particularly by Senator McCain - who, in a sense, would take the current exclusion of employer provided health in from employee incomes and turn it into a series of tax credits.

So if you're an employer that is providing very deluxe coverage and you're in a high cost area as far as health care, some of these benefits you're providing employees may no longer be tax free, so you won't be happy about that. On the other hand, if you're providing less expensive, less extensive coverage, or in a low cost area, perhaps your employees will get some benefits compared to where things are today.

CHIDEYA: How big of an issue is the debate over public insurance, whether it's single pay or other forms of public insurance? I mean, for example, when you look at the Republican candidates and the Democratic candidates, the Republican candidates generally are looking at ways of using market forces for private health care insurance. Both of the Democratic candidates have some plans, different plans to put more public insurance into the mix. Is that just a fundamental party difference?

Mr. GINSBERG: Yes. Actually, what's striking is how nobody - or at least none of the major candidates - are advocating single payer systems today. I think the Democrats - and I'm talking about, you know, Clinton and Obama - really are taking their cues from Massachusetts.

Because Massachusetts two years ago was able to put together a political compromise that everyone got behind and that all the stakeholders got behind, which was a mixture of expanding public programs for low income people, like Medicaid program and the SCHIP program, together with subsidies for, you know, low income but somewhat better off people to purchase private insurance.

And I've always thought that setting the stage for this round was this compromise between an expansion of public programs and more subsidies for private coverage.

CHIDEYA: SCHIP is the children's insurance program that became a huge political fight between the administration and Congress, the Democrats in Congress particularly. Is something like SCHIP, which provides insurance specifically for children, something that the candidates generally agree on across party lines? Or how does that play out?

Mr. GINSBERG: Yes, well I suspect that most candidates would be in favor of at least continuing CHIP, but the Democrat candidates would like to expand it as far as their plans for universal coverage. What really surprised people in this SCHIP controversy between the president and the Democrats in Congress was that it came up.

Because many people, I would say going six months back, felt that there would be ultimately a compromise that involved expansions of Medicaid and SCHIP, and more subsidies, usually through the tax system, for private insurance. But it may have been that the president didn't want the starting point to develop this compromise to be a much expanded CHIP program from where it is today.

In a sense, he may have just wanted to keep it where it is, and then perhaps Republicans and Democrats would compromise from where it is today rather than from a greatly expanded program.

CHIDEYA: Well, Paul, thank you for your time.

Mr. GINSBERG: Oh, you're very welcome. Pleasure.

CHIDEYA: Paul Ginsberg is president of the Center for Studying Health Care System Change. And he joined me from NPR D.C. headquarters in Washington, D.C.

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