Plans to reform health care run the gamut

KANSAS CITY, Mo. - In the debate over how to reform health care, that's what everybody wants to know. There are at least 10 packages on the table, from a single-payer, government-owned insurance program on the left to a conservative plan that aims to get government out of health care.

Neither approach is likely. Instead, like hungry truckers at an all-you-can-eat buffet, members of Congress are picking and choosing among more centrist policy options that would use current programs, scrap others and build on existing systems.

The idea: assemble a full plate of health care reform Americans can digest at a cost they can afford.

"Let's fix health care next," says a new video ad from a group headed by Bob Dole, Tom Daschle and Howard Baker, three former senators who last week unveiled a plan.

Easy to say, but tougher to do. Some of the thorniest issues remain unresolved, and critics, such as Sen. Pat Roberts, a Kansas Republican, seek to slow the process so the costs and effects of reform are more clearly understood.

And there is a growing possibility the effort could collapse.

Still, all sides basically agree on some of the easier parts of reform, suggesting a compromise on some issues is likely:

Insurance companies (private or public) would be required to cover you regardless of your health or prior chronic conditions. Premiums may be capped or subsidized by taxpayers. Costs for seriously ill patients may be spread among several insurance providers.

States, and maybe the federal government, would establish health "exchanges" that could provide apples-to-apples cost comparisons for insurance policies. Some proposals go further, suggesting government-supported "co-ops" in which individuals and businesses could buy coverage.

Individuals and businesses would be eligible for larger tax credits to buy insurance for themselves or their employees. Medicaid for the poor may be expanded, while Medicare for the elderly would likely be cut.

The government would emphasize wellness, early intervention and preventive care - and would require insurers to cover more early testing and treatment (the law may reward healthy behaviors). More taxpayer money would be made available to train doctors, nurses and other providers.

But those providers and insurers may be asked to justify their costs as pressure is increased to keep health care prices low.

Those changes, though, would be relatively simple. The real fight would come over three policy choices where compromise appears difficult.

Some lawmakers - looking at 45 million to 47 million uninsured Americans - want to require everyone to get insurance, as some states do. Some plans also would require most businesses to provide it for workers or pay into a fund that would provide coverage, a system known as "pay or play."

"Most Americans are already insured," said the Dole-Daschle-Baker group, "so requiring them to (say) on their income tax forms that they have insurance will go a long way to ensuring coverage for all."

Covering those without insurance would bring in billions in new premiums, especially from younger, healthier workers whose money could provide treatment for their sicker elders. Requiring everyone to have insurance might also cut down on expensive trips to the emergency room by the uninsured, as well as improve early detection and response - further cutting costs.

But businesses are expected to oppose a mandate, which could drive up costs and make them more reluctant to hire.

"An employer mandate ... is a job killer, potentially costing 1.6 million jobs - hardly what this country needs," said the National Federation of Independent Business.

Some liberals say requiring individuals to have coverage could be a hardship for the poor, even with tax credits and other subsidies to pay the premiums. They also worry about punishing those who would ignore a mandate.

House Democrats and President Barack Obama want to establish a government health insurance alternative to private carriers. Supporters say a public option would provide competition for private companies and bring down the price.

But most Republicans and some Democrats oppose a public option, which they say would be the first step toward national health insurance. Senate Finance Committee Democrats also worry that a public option would make health reform far too expensive.

Some providers are also concerned. Government insurance, they say, would become so widespread that Washington could force cost reductions that would lead to rationing.

Obama rejects both views.

"The public option is not your enemy; it is your friend," he told doctors last week. "So when you hear the naysayers claim that I'm trying to bring about government-run health care, know this: They're not telling the truth."

House GOP leader John Boehner of Ohio countered: "Do Democrats really believe that the government that brought you the AIG bailout mess or a $1 trillion 'stimulus' plan really has the credibility to run America's health care?"

Some analysts think establishing a public option could make the problem of the uninsured worse if businesses drop coverage and tell their workers to use the government plan, as many are expected to do.

Candidate Obama ridiculed opponent John McCain for suggesting health insurance benefits provided by employers should be taxed as regular income for workers. But virtually all of the centrist reform plans would tax all or part of health benefits, although some would ease the pain by allowing credits and deductions for lower-wage workers.

Many Republicans and Democrats say taxing benefits would raise billions and be fairer to the self-insured, who get no such tax break now.

Not everyone supports taxing benefits. A GOP health care option unveiled last week by Rep. Roy Blunt of Missouri did not include such a levy. But it was vague on where reform money would come from.

The public doesn't like the idea either. A recent NBC/Wall Street Journal poll showed 70 percent of those surveyed opposed taxing health benefits.

The alternative? General tax increases. Options include a tax on soft drinks and alcohol, higher taxes on the wealthy, raising the payroll tax and a national sales or value-added tax.

Threading the needle on all three components will be extraordinarily difficult, in part, because they interlock. Change the public option, for example, and mandated coverage becomes more expensive - increasing the need to tax health benefits or raise taxes.

But, Obama argues, the price of doing nothing is worse.

He told the doctors: "Health care is the single most important thing we can do for America's long-term fiscal health."

(c) 2009, The Kansas City Star.

Distributed by McClatchy-Tribune Information Services.