Dr. James Rohack is optimistic change is coming to health care coverage in the United States.

Otherwise, the fallback is the system created in 1986 that puts the burden of providing care to the uninsured on hospital emergency rooms, said Rohack, director of Scott & White Center for Health Care Policy and president-elect of the American Medical Associ-ation.

It’s a failed system, because providing primary or preventative care in emergency rooms is both expensive, unproductive and results in the costs of care to be shifted.

Sen. John McCain, Repub-lican presidential candidate, keeps health care coverage in the private sector, with an attempt to improve access by creating refundable tax credits.

Tax credits for an individual would be $2,500 a year and $5,000 a year for a family if health insurance is purchased, regardless of income level.

McCain also stresses health information technology and reducing waste in the system, Rohack said.

“All good goals,” he said.

The estimation is that McCain’s plan might cover an additional 10 million Amer-icans, Rohack said. Another estimation is as high as 25 million out of a total of 47 million who have no coverage.

“While McCain’s plan will help, depending on which statistic you look at, it’ll cover a third or less of those who are uninsured,” he said.

The plan proposed by Sen. Barack Obama, Democrat presidential candidate, takes a different tack, requiring a mandate of health insurance, whereas the McCain plan is voluntary, Rohack said.

The mandate is only for those up to age 25, with subsidies to try to make sure everybody has coverage, he said.

Because of the mandate, the Obama plan covers more people - up to 30 million or 35 million Americans.

“Beyond that, the plans are similar with both encouraging healthy behavior and reducing waste,” Rohack said. “The major difference is the mandate and national insurance plan in the Obama plan.”

Both candidates have a focus on improving quality of care and improved information technology.

In regards to financing, McCain’s plan is not specific, but cost containment will play a role in making insurance affordable. His plan calls for promoting competition among providers and paying only for quality.

Rohack said Medicare is looking at part of its cost containment efforts to include only paying for perfection - not paying if a patient gets a bedsore while in the hospital or for infections that develop while in the hospital.

“Part of the aspect of reducing costs is to make health care perfect and to have no waste,” he said.

That’s a laudable goal, Rohack said, but the practicality is that to create such an environment is a work in progress.

Bar coding pharmaceuticals is a good idea, as is providing colored bands for patients allergic to particular medications, he said.

“We have yet to agree on what color the band should be,” Rohack said.

The Obama plan would finance the health plan in part by repealing tax credits for those with income over $250,000.

The tax credit proposed by McCain doesn’t help those whose salaries put them at the bottom of the socioeconomic scale and would have to spend more than 10 percent of their take-home pay for insurance, Rohack said.

“A tax credit only makes sense if it’s advanceable - you can get it ahead of time to buy your health insurance, rather than after the fact,” he said.

Texas leads the nation in the number of uninsured and neither campaign has talked about how to deal with undocumented workers, Rohack said.

If the system is totally changed, there has to be a way for Texas and other border states to cover that portion of the population or they will continue showing up in emergency rooms seeking care, he said.

There needs to be individual products and a mechanism in place to determine types of insurance needed by those coming to the emergency room without health care coverage. Depending on income, the person would either be assigned a policy or given a partial subsidy to purchase insurance.

Rohack believes health care will change in this country because enough people recognize the 1986 Emergency Medical Treatment and Active Labor Act is not a model that works.

The act states that hospitals have to take care of anybody who shows up at their door, regardless of ability to pay.

“We have to create a program where people have their own health insurance so they can get preventative care treatments,” Rohack said.

It makes sense that a child with asthma be able to get medication and treatments from a medical provider, rather than a weekly trip to the emergency room, he said.

There is a need to educate the business owner to the fact that a healthy worker who has access to medical care is more productive. There are no easy answers, Rohack said.

Providing employers with affordable insurance will require making the tough decisions on what is covered … what is essential.

“The reason I’m optimistic is because baby boomers are heading toward Medicare,” he said. “Look at what they did in the 1960s. They burned their bras, they burned the draft card … they made fundamental changes in civil rights. The United States in the 1960s made tremendous public policy shifts because of those forces.”

In 1965, there were eight workers paying the taxes that funded Medicare for each recipient. When the baby boomers hit the Medicare roles there will only be four workers for each person on Medicare.

“If those workers aren’t healthy and working, nobody is paying the taxes,” Rohack said. “Now, there’s more of an interest.”

Workers need insurance and both McCain’s and Obama’s programs, he said, have incentives to continue to keep a healthy population that will work and then pay the taxes for the baby boomers’ Medicare.

Medicaid is another issue.

The usual picture of Medicaid is the young pregnant woman, while a more realistic picture, according to the budget, is nursing home care.

Breaking the budget of Medicaid is not acute care, but long-term nursing home care, Rohack said. Medicare doesn’t pay for long-term care and Medicaid, by default, has become the long-term nursing home insurance.

From a public policy standpoint, he said, the issue is should Medicaid be federalized for the acute care portion of the program and provide a fixed dollar amount that the individual can use to buy an insurance policy that they own.

“It’s going to be a very interesting time,” Rohack said of the presidential race.

Editor’s note: This is the first in a series about where John McCain and Barack Obama stand on issues that affect Central Texans.

Monday: A look at each candidate’s plan for veterans.