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These are questions undecided voters from Kew Gardens to Rochester are asking, as both Sen. Barack Obama and Sen. John McCain have pledged to offer affordable, more comprehensive health care to the country's 46 million uninsured.
But each of the plans comes with different costs for the Empire State.
Experts say Obama's proposal coincides with the policies of the Paterson administration. It would, in effect, ease the tax burden on New Yorkers who pay for the state's expansive, and expensive, Medicaid and children's health insurance programs. McCain's plan would represent a fundamental shift in how New Yorkers receive care, but many New York health policy experts say it would offer few benefits to most state residents.
The Plans In Context
When the candidates debated in Long Island on Oct. 15 they again outlined their approaches.
Obama wants to expand the country's children's health insurance program and Medicaid. For people who do not get insurance from their employer, he plans to set up a federal health registry that would allow anyone to purchase subsidized medical insurance that rivals the benefits that members of Congress receive. An attempt at universal health care, the plan would require all businesses -- except "small businesses," a term he has not yet defined -- to either offer insurance or help out with the cost.
McCain would do away with the current tax exemption for employer-provided health insurance and hand out tax credits of $2,500 for individuals and $5,000 for families. Those credits would be used to purchase individual insurance plans, and any extra would go into a health savings account. The tax credits would go to the insurer, so any benefits someone receives would consequently be subject to income taxes -- it would be like those tax credits had been tacked onto your salary. McCain would then deregulate the industry to allow people to purchase insurance in other states. For example, a New Yorker could sidestep our high cost of insurance and purchase a cheaper plan in, say, Alaska. McCain's plan relies on the free market to balance quality care.
But how will each of them work out here? For one, the state is home to a large number of immigrants, who have been left out of both plans entirely.
In 2007, 13 percent of the state's population was uninsured. Some estimate we have the highest cost of health care in the country. Nearly half of New York's 2.5 million uninsured have a household income of less than $40,000, according to the U.S. Census Bureau. About 11 million people in New York received insurance from their employer in 2007, according to the U.S. Census Bureau.
Shrinking Care and Adding Cost
Taxing individual and family health care plans, as McCain suggests, has never been done before.
"McCain's plan is odd," said Jonathan Engel, a professor of public policy and associate dean at Baruch College. "I have seen a lot of health reform plans over the years and most of them have something going for them." This one, said Engel, doesn't have much. "It's a huge tax increase on the middle class," he said.
New York's health care policy experts agree that McCain's plan would not do that much for the Big Apple. Sherry Glied, a professor at Columbia's Mailman School of Public Health, said McCain's proposal to deregulate the insurance industry and allow individuals to buy policies in other states could help young, healthy people. They can afford to get cheaper care and less coverage. The state's older, sicker population, though, could end up suffering, she said.
"If you're young and healthy, it's a good thing," said Glied. "The old and sick -- any other state would rate them according to their health status, and we don't allow them to do that."
In 1992, then Gov. Mario Cuomo signed legislation aimed at removing stigmas and discrimination in the state's insurance industry. He established a community health rating system, which pooled the risks of an entire area. It raised rates for younger people, but kept rates for older individuals reasonable.
If individuals could purchase policies out of state, Glied said, the state would probably have to do away with that rating system, effectively raising rates for people who are more of a risk to insure, like those with chronic illnesses.
"It's junk bonds in terms of health insurance," said Darryl Ng, director of government affairs for the Community Health Care Association of New York. "You lose a lot of hard-fought consumer protection."
Other experts question whether small businesses, which currently offer their employees insurance, would drop their plans if the employees were taxed. Some groups, including the U.S. Chamber of Commerce have expressed fear such a change might encourage younger, healthier workers to drop their employee insurance plans, driving up the cost of the overall plan for those that remain. Under the McCain plan, said Paul Howard of the Manhattan Institute's Center for Medical Progress, larger companies would likely still provide employees with insurance plans, but small businesses might not. Howard, who favors the McCain plan, said free market principles would dictate the insurance market and eventually lower the cost of insurance for everyone.
"The employer-provider health insurance system right now is under stress," said Howard. "Both the McCain and the Obama plans are actually going to wind up pushing more people into different types of coverage."
Whether the McCain tax credits will be able to cover the cost of insurance in New York is also unclear. Howard S. Berliner, chair and professor of health policy and management at SUNY Downstate Medical Center, estimates the cost of an individual insurance plan in New York is $6,000 and between $12,000 and $13,000 for a family. McCain's credits, he said, do not come close to covering that cost.
Obama's plan calls for a nationwide expansion of Medicaid and the country's state children's health insurance program, otherwise known as SCHIP and Child Health Plus here in New York, meaning that the federal government would pick up costs now borne by the state. New York has the second largest Medicaid system in the country.
"SCHIP is something that New York is paying for," said Ng. "We are paying for that out of our New York City taxes. Obama's plan would set the national standard. That would be a great resource we would get the feds to pay for."
Earlier this year, the state approved an expansion of the children's health insurance program to cover families with incomes up to 400 percent of the poverty line. Throughout the last several months, Albany has clashed with the Bush administration over covering families with that much income -- about $83,000 for a family of four.
Obama's plan includes that expansion and would then subsidize the state's program with federal tax dollars.
"Obama's plan is a plan that is using a lot of building boxes to expand coverage," said Glied. "It would be comparable to things that are already happening in the state."
The second element of his plan, said health care experts, would set up a national health care bank for purchasing insurance.
When health care reform was thrust to the center stage in this year's presidential election, no one anticipated the turmoil on Wall Street and the type of recession economists now predict.
That said, most health care policy experts say any real reform will likely be shelved for the time being. The next four years will not be about reform, but about keeping us afloat.
"With the wide ranging deficits in the next couple years, it's going to be very difficult," said Howard. "State reform will be delayed and (so will) congressional universal health care reform under the next president -- either McCain or Obama."
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