As has been widely noted in Obama commercials, McCain's plan relies heavily on a health insurance tax credit. Recognizing that the free market approach won't work for everyone, McCain's plan relies on a dramatic expansion of state-sponsored high-risk pools.
So he is calling for a guaranteed access plan, a federal effort to share the cost of high-risk pools and dramatically expand their reach -- from fewer than 200,000 Americans in state plans today to perhaps 5 million.
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Among the high-risk pools in 34 states, Minnesota's is the oldest, largest and, many believe, the most successful. "It just seems to work," said Doug Holtz-Eakin, senior policy adviser to McCain.
Created in a wave of health-care changes here in the late 1970s, the Minnesota Comprehensive Health Association (MCHA) had a membership of 28,000 last year, equaling nearly 7 percent of the state's uninsured population. Small as that share was, it far exceeded any other state's, according to the National Association of State Comprehensive Insurance Plans.
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McCain has said that, under his guaranteed access plan, the federal government would cover half the cost of such pools, with the rest paid by states and the insurance industry. In the spring, Holtz-Eakin estimated that the federal share might be $7 billion or $8 billion a year. "It's going to be twice that, realistically," he said in a recent interview.
Obama's plan, of course, follows a different model -- that pursued by Massachusetts.
Lynn is one of 439,000 people here who have gained insurance since Massachusetts embarked two years ago on a path to near-universal coverage. More than half of them are paying toward it; the rest, like Lynn, get it free. How close Massachusetts can come to its goal -- and what obstacles it encounters -- is significant, because its strategies resemble much of the approach to health care that Obama has said he would pursue if elected president next week.
Obama says he would keep the familiar arrangement in which most Americans get health insurance through their jobs, as Massachusetts is doing. Yet he also favors profound -- and controversial -- changes that Massachusetts also is putting in place: Expanding government insurance programs and subsidies. Requiring employers to offer their workers coverage or face penalties if they do not. Forbidding insurance companies to reject anyone or charging more if they are sick. Creating a national health insurance exchange to help people to find and compare private insurance policies on their own.
In the most significant departure from the Democratic nominee's thinking, Massachusetts has imposed a mandate that requires most adults to carry health insurance -- and fines them if they refuse.
In the 31 months since the experiment here began, the share of working-age people without health insurance has plunged -- from 13 percent to 7 percent by one estimate -- more sharply and quickly than anyone expected, leaving Massachusetts with the lowest uninsured rate in the country. But the unexpected number of people also has translated into higher-than-expected costs. Massachusetts has been forced twice to scrounge for extra money, totaling more than $250 million this year and last, from state funds and other places.
