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Now, one of the quickest ways to pay for a health-care change would be to tax the most expensive health-care plans. In fact, we're hearing elsewhere on today's program from a Democrat senator who wants to do just that - tax the Cadillac plans, is the way they put it. The assumption is that would mean a tax on the rich, but that's not always true. NPR's Joseph Shapiro explains.

JOSEPH SHAPIRO: While you've been trying to follow the ins and outs of the health-care debate, you've probably heard some reference, like this one, to people with high-cost health insurance.

(Soundbite of TV show, "The NewsHour with Jim Lehrer")

President BARACK OBAMA: What's been talked about now, I understand, is the possibility of penalizing insurance companies who are offering super-gold-plated Cadillac plans.

SHAPIRO: That was President Obama last week on PBS on "The NewsHour with Jim Lehrer." Those super-gold-plated Cadillac plans the president was referring to were the kind of health insurance that's offered to top officials at the Wall Street bank Goldman Sachs. Senator John Kerry has proposed taxing insurance companies when they offer these expensive plans. On average, American employers pay almost $13,000 a year to cover a worker with a family.

Those Goldman Sachs plans cost about $40,000. But some proposals in Congress would tax insurance that costs half that much, or even less. That's when things get murkier, and it might be you who's driving that Cadillac plan.

Mr. LEN BURMAN (Economist, Urban Institute): Yeah, it's probably not just rich people. I mean, actually, government employees get really generous health-insurance plans. Unionized employees can get very generous health-insurance plans.

SHAPIRO: That's Len Burman, an economist with the Urban Institute. He said there are a lot of reasons people end up with expensive health care. You probably pay more if you work for a company that has an older work force or for a small business, especially if one of your co-workers is fighting cancer or some big medical cost, and the insurer has just raised the rates for the whole company.

Still, if economists made the decision, they'd probably go for a tax on the high-cost insurance, specifically another proposal - popular with congressional Republicans and centrist Democrats - that would require people to pay a tax on health-care benefits more than a certain amount, maybe $17,000 or more. Len Burman.

Mr. BURMAN: Some people have very generous health-insurance plans. And they encourage them to spend more on medical care than they would if they had less generous plans. So part of the idea is that if you limited the tax benefits for the very generous health-insurance plans, people would spend less and that would actually help lower health costs overall.

SHAPIRO: Your employer pays for most of your health insurance. But that money doesn't get counted as part of your taxable income. Burman says that's unfair because employees with the most income get the biggest tax break. Burman thinks it'd be pretty easy to set a cap, so it doesn't hurt middle-class people. Union leaders aren't so sure, like Gerald McEntee, president of the American Federation of State, County and Municipal Employees. He says many of the public employees he represents have plans that do cost $20,000, but only because they gave up other things in contract negotiations.

Mr. GERALD MCENTEE (President, American Federation of State, County and Municipal Employees): They have struggled, giving up wage increases, giving up fringe benefits, things of that nature, in order to get good, good health plans that would cover themselves and their spouse and children so that they would be safe.

SHAPIRO: Some people pay more for health insurance simply because of where they live, in big cities, or in New England states like Maine. Trish Riley runs the Maine Governor's Office of Health Policy and Finance. She says a tax on premiums would hurt many people in her state, particularly government employees and people who work for small companies.

Ms. TRISH RILEY (Director, Maine Governor's Office of Health Policy and Finance): It would, I think, hit many of the middle class who are - again, we're a state of modest means.

SHAPIRO: Maine has some of the highest insurance premiums in the country. Among the reasons, the state has an older population and lots of small businesses. Plus, health care just costs more there.

Ms. RILEY: And people are increasingly being asked to pay for the deductibles. So the premium, I think, is not fully telling of the real costs to an individual employee.

SHAPIRO: Still, there's one reason policy makers in Washington keep coming back to a tax on benefits: It would raise tens of billions of dollars a year to cover health care.

Joseph Shapiro, NPR News.

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