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STEVE INSKEEP, host:

A lot of Americans are thinking about the money that we spend on health care. That's true even though it's no longer the top domestic issue in the presidential campaign.

A poll out last week found that more than 80 percent of those surveyed think the nation's health-care system needs fundamental change. So it's no surprise, then, that both Senators John McCain and Barack Obama are promising major change. As NPR's Julie Rovner reports, that's about all their plans have in common.

JULIE ROVNER: When it comes to health care, there's one thing Republican John McCain and Democrat Barack Obama do agree on: The current system doesn't work very well. Here's Obama.

Senator BARACK OBAMA (Democrat, Illinois, Presidential Candidate): We spend $2 trillion on health care every single year. We spend twice as much per capita as the next-nearest country.

ROVNER: And here's McCain basically finishing that thought.

Senator JOHN McCAIN (Republican, Arizona, Presidential Campaign): And the inflation associated with health care has been at double digits or near that, and we cannot stand that.

ROVNER: But McCain and Obama have very different prescriptions for solving that problem, says Jonathan Oberlander. He teaches health politics and policy at the University of North Carolina at Chapel Hill.

Mr. JONATHAN OBERLANDER (University of North Carolina, Chapel Hill): There are many issues where Obama and McCain differ. I'm not sure there's any issue where they differ as much as this.

Sometimes we complain in politics that Democrats and Republicans run to the center, and they copy each other with their proposals. At least in health care we don't have to worry about that.

ROVNER: Of the two candidates, McCain is arguably the one whose plan would change the health system the most. Right now, if you get health insurance from your employer, you don't pay taxes on the value of that benefit. But if you have to buy your own insurance and you're not self-employed, you don't get any tax help. McCain would change that, making employer-provided insurance taxable but then giving everyone a tax credit.

Sen. McCAIN: Our proposal is to give every family in America a $5,000 refundable tax credit, and they take that tax credit and go online and pick out the insurance policy they want, notify the government, and that health insurance will be provided.

ROVNER: There's lots of questions about McCain's plan. How hard will it be for people who are already sick to buy insurance? Will people really be able to find policies they can afford when the average family policy now costs more than $13,000?

And does the public really want to move away from a system in which employers provide most people's health insurance to one where most people buy their own?

But McCain says in the end, there's one main reason he wants to move in the direction he's chosen rather than the one being pursued by the Democrats.

Sen. McCAIN: I want the families to make the choices. They want the government to make the choices.

ROVNER: But what Obama is proposing isn't really government-run health care. It doesn't even have a requirement for individuals to have coverage, like the plans offered by his main primary opponents, John Edwards and Hillary Clinton. Obama says under his plan, if you already have insurance you like, you can keep it.

Sen. OBAMA: But if you're one of the 45 million Americans who don't have health insurance, you will have health insurance that's available to you. No one will be turned away because of a pre-existing condition or illness.

Everyone will be able to buy into a new health insurance plan that's similar to the one that every federal employee currently has for themselves.

ROVNER: And if you can't afford coverage, you'll get a subsidy. Employers would have to offer coverage to their workers, but they'd get government help, too. Political scientist Oberlander says the McCain and Obama plans would essentially move the system in exactly opposite directions.

Mr. OBERLANDER: While Senator Obama wants to build on top of the employer-sponsored insurance system, Senator McCain wants to build away from it and move more people into the individual insurance market.

ROVNER: In fact, says Oberlander, in many ways the current debate reminds him of the movie "Groundhog Day," except he keeps waking up and thinking it's 1992.

Mr. OBERLANDER: And in 1992 the stock Democratic health-reform solution, before Bill Clinton changed it, was a play-or-pay employer mandate, and that's exactly what Barack Obama has. And in 1992, the favorite Republican solution was tax credits to buy private health insurance.

So a lot of things have happened in 16 years. The health-care system is much worse than it was, but we pretty much have the same solutions that we've always had.

ROVNER: And voters have pretty much the same choice. Julie Rovner, NPR News, Washington.

INSKEEP: To see where the candidates stand on other key issues, check out NPR.org's online election coverage.

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