STEVE INSKEEP, host:
Much of the presidential campaign is focused on the candidates' personal stories, but you can find differences on the issues, and this morning we are going to examine one of those issues, healthcare. Barack Obama and John McCain contend we do not need sweeping mandates to get all Americans insured. Senator Hillary Clinton, however, favors a health plan similar in some ways to a law in Massachusetts.
That 2006 law requires nearly every citizen to sign up for health insurance or pay a tax penalty. This morning NPR's Richard Knox checks in on how the Massachusetts plan is doing.
RICHARD KNOX: Dee Cook is just the kind of person the Massachusetts insurance law is aimed at. She's a 59-year-old hairdresser.
Ms. DEE COOK (Hairdresser): I've don it for 40 years. Yeah. Yeah, in March it will be 40 years since I got out of hair dressing school.
KNOX: Cook hasn't had health insurance for 13 years. Her current employer doesn't provide it and she hasn't been able to afford it.
Ms. COOK: My children have been on me about it. You know, Mom, you really need to get some health insurance. But up until last year, I just got out of debt management last year. I finished paying everybody off.
KNOX: Finally, last November she signed up just under the deadline.
Ms. COOK: I had to get it because of the new laws.
KNOX: Cook is one of 16,000 or so Massachusetts workers to sign up for health insurance that they pay for entirely by themselves. Most of those who've signed up in Massachusetts are poor and near poor people who get coverage heavily subsidized by the state. Leslie Curwen(ph) is the state's top budget official. She also chairs the new agency set up to implement the new insurance law.
Ms. LESLIE CURWEN (Budget Official, Massachusetts): I think it's a great success so far. We've celebrated 300,000 people newly enrolled in health insurance, which is a real milestone.
KNOX: In fact, you might say the Massachusetts plan has been too successful. Tens of thousands more people have signed up for state subsidized coverage for poor and near poor than state officials expected.
In effect, the new law has smoked out far more uninsured citizens than the state knew existed. That's led to some confusing headlines implying cost overruns in the range of $400,000,000. In fact, Curwen says, most of that was planned growth. The overrun is closer to $120 million - a worry, she says, but not a catastrophe.
Ms. CURWEN: Is it without concern? Certainly not. We know that the sustainability of it financially is a concern. We need to work on that.
KNOX: Massachusetts' biggest worry at the moment is whether the Bush administration will renew a Medicaid waiver that allows the federal government to pay for about half the program. Recently the administration has told other states they can't use federal money for similar subsidies of the near poor.
Ms. CURWEN: It is absolutely critical that we maintain the support of the federal government for this program.
KNOX: Beyond the details, though, the Massachusetts program poses a question at the heart of the national debate. Is it going to be necessary to mandate that all individuals buy insurance in order to get to universal coverage? Hillary Clinton thinks so. Jonathan Gruber, an MIT economist who's on the board of the new Massachusetts agency, agrees.
Mr. JONATHAN GRUBER (Department of Economics, Massachusetts Institute of Technology): If you just simply said, we are going to take the kind of Massachusetts-style plan, you know, subsidies and a new reformed insurance market. And we are not going to have a mandate; you can at best cover about half the uninsured.
KNOX: Without a mandate he says, people with higher medical expenses will sign up, but many who don't expect to need care will stay out.
Mr. GRUBER: The right way that insurance works is that people have insurance all the time so that when they are healthy, they pay more than they would spend in that given year. When they're sick, they collect more than they pay in that given year. That's the whole idea of insurance.
KNOX: Barack Obama doesn't like mandates, except for covering children. He says penalties have to be too stiff to force people to buy coverage. John McCain doesn't propose mandates at all. Instead, he favors tax credits. Both believe if health insurance is made affordable, people will buy it, although Obama and McCain have major differences on how to do that.
But the debate over how to achieve universal coverage isn't just to the right of Clinton; many to her left also oppose mandated health insurance, like Bob Kuttner, co-editor of the American Prospect magazine and a Boston Globe columnist.
Mr. BOB KUTTNER (Co-editor, The American Prospect; Columnist, Boston Globe): It's a very bizarre position for a liberal to be in, to say to the citizen, rather than providing a service that's tax-supported because you as an American ought to have this service, we are going to make you go out and find something or you pay a penalty. This is exactly the sort of thing that causes people to resent government.
KNOX: Kuttner favors government sponsored health coverage, sort of Medicare for all. But he acknowledges that some kind of intermediate step, perhaps a mandate on employers to buy insurance, might be necessary. It seems safe to say that the debate won't be settled by November's election, so the Massachusetts experiment will remain relevant. Dee Cook, the newly insured hairdresser, is reserving judgment on it. I asked her if she thinks the Massachusetts law is a good thing.
Ms. COOK: Check back in a couple of years. See how it's working.
KNOX: Even staunch supporters of the Massachusetts plan say it's too early to declare it a success and it's too soon to call it a failure. Richard Knox, NPR News, Boston.
INSKEEP: We'll look more deeply at this issue on Monday when we will check the differences between the two leading Democrats on how they would achieve health coverage for all Americans.
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