Fifth in a series examining presidential candidates' positions on campaign issues

When Rep. Bobby Rush, D-Ill., stood before a small crowd at the Duchossis Center for Advanced Medicine in Chicago this month, the eight-term congressman who easily defeated Barack Obama for a House seat in 2000 had a different victory on his mind: With labored speech, Rush spoke of his five-month battle with a rare form of jaw cancer.

Doctors recently declared Rush cancer-free, but the 61-year-old congressman wonders how he would have fared without his federal health-care insurance. "I am a member of Congress, and I have access to the best medical care in the nation," said Rush. "I can't be satisfied until every American has access to this same kind of care."

For Jake Smith, access to health care isn't the problem. The hardship is paying for it. The 80-year-old retired truck driver from North Carolina recently sold his home of 33 years to settle about $15,000 in medical debt incurred for his late wife's cancer treatment at Duke University.

The couple relied on Medicare as their only source of health insurance. Smith told The Raleigh News and Observer they didn't qualify for Medicaid, but couldn't afford a private plan to cover the gaps left by Medicare. He's paying those out of pocket. From his small, one-bedroom senior housing apartment in downtown Durham, Smith said selling his home was his only option: "I believe in paying what I owe."

In a presidential campaign marked by stark differences, Obama and Sen. John McCain agree on at least one thing: Health care in the United States desperately needs reform. According to the U.S. Census Bureau, some 47 million Americans are uninsured, and many insured Americans can't keep up with the skyrocketing cost of health care.

But when it comes to the how-to of overhauling the system, the candidates differ sharply. Voters sifting through their complex proposals must wrestle with a fundamental question: Which underlying philosophy of government do they agree with most?

For Obama, one goal looms large: quickly reduce the number of uninsured Americans. While the senator says Americans could keep employer-based and private care, he aims for universal health care anchored in a national health-insurance program administered by the federal government.

The candidate says the national health-care program would offer coverage comparable to federal insurance available to members of Congress. He says anyone could enroll in the program regardless of age or preexisting conditions, and premiums would be affordable.

The candidate hasn't given concrete numbers on consumer costs, though he says the average family would save about $2,500 under his plan. Some health-care analysts say it's unclear whether those savings would materialize.

For those struggling to buy coverage, Obama proposes offering federal subsidies to buy into the federal program or purchase private insurance. Those with employer-based or private plans could switch to the federal program as well.

Unlike his Democratic primary challenger, Sen. Hillary Clinton, Obama wouldn't mandate that all Americans carry health-care insurance. The candidate says health care must be affordable before requiring all to buy it. But Obama would mandate coverage for all children and proposes expanding the SCHIP and Medicaid entitlement programs.

Obama would lay a mandate on all employers as well: Those that don't offer health-care benefits to employees would be required to contribute a percentage of their payroll to the national program. He says small businesses would be exempt, but some small-business owners worry about whether the exemption would apply to them.

Obama says his plan would cost between $50 billion and $65 billion a year, but some health-care analysts estimate the plan could cost taxpayers twice that figure. The candidate says he would pay for his plan by ending the Iraq war and repealing President Bush's tax cuts for households earning more than $250,000. But Michael Tanner of the Cato Institute told WORLD the candidate has promised that same money for any number of spending proposals.

Tanner says he believes Obama rightly wants to cut costs, but he worries about what he calls "a command and control approach-a lot of regulations, a lot of government direction." Tanner adds: "I think Sen. Obama's plan is a recipe for having the government run our health-care system, and so far I don't see any reason to believe that they're capable of that."

When it comes to McCain, another goal looms large: cutting costs. The senator opposes mandating coverage or creating a federally operated health-care system, saying both would swell government spending. Instead, McCain favors a market-based approach aimed at giving individuals affordable options in the private sector.

McCain's plan could represent a radical shift in the health-care system: It encourages a gradual move away from employer-based plans. McCain would eliminate the tax deduction on employer-provided insurance and instead provide tax credits for individuals to purchase their own coverage. The plan calls for a $2,500 credit for individuals and a $5,000 credit for families.

Though workers could keep their employer-provided insurance, McCain says the tax credit would encourage individuals to shop around for a better deal. That would create more competition in the private market, he says, and drive down costs.

Cato's Tanner says moving away from employer-based coverage is an idea many economists embrace: "There's no logical reason your boss should choose your health insurance." It's also an idea some Democrats have embraced: Portable health-care coverage is a key piece of a bipartisan health-care proposal in the House.

Critics say McCain's plan could lead some employers to stop providing coverage. McCain adviser Gail Wilensky says workers shouldn't worry. "I can't imagine most large employers not continuing to offer health-insurance plans for the foreseeable future," she said. "Ten or 20 years down the road-who knows?"

Critics also say the McCain tax credits wouldn't be enough to offset the cost of purchasing private insurance for many individuals and families. Health insurance for a family of four averages $12,000 a year, according to a recent Kaiser Family Foundation study. McCain says his plan would drive down costs, but analysts say those changes would come slowly.

Tanner likes McCain's market-based approach to health care, but he points out problems. For instance, McCain's plan to use tax credits could turn into a bidding war in Congress to see who could "be most compassionate by offering the biggest tax credit." That could drive up costs, he says.

But he points out a larger problem: Tanner says McCain hasn't yet streamlined his proposals into a cohesive plan. "It risks being seen as individual pieces . . . rather than a comprehensive whole," he says. "And if you try these reforms piecemeal, you're apt to create more problems than you solve."

Back at the gathering in Chicago earlier this month, Rep. Rush thanked his doctors for his treatment and told the crowd that he favors universal health care. But he also acknowledged something more important in his recovery: With clasped hands, the former Black Panther lifted his head and publicly thanked God.

On the record

Obama

McCain