If the U.S. Supreme Court throws out the federal health care law, the question becomes: "What then?"
All three major Republican candidates for U.S. Senate in Nebraska support the repeal of President Barack Obama's Patient Protection and Affordable Care Act in its entirety, including popular provisions that require insurance companies to cover people with pre-existing conditions and end the insurers' lifetime caps on covered expenses.
However, none of them has put forth a comprehensive plan to overhaul the nation's system of insuring health care.
Nebraska Attorney General Jon Bruning, State Treasurer Don Stenberg and State Sen. Deb Fischer all said they would look for ways to reduce health care costs once in office, including allowing insurance companies to compete across state lines, fostering larger insurance pools for small businesses and limiting medical malpractice lawsuits.
None has embraced the controversial House GOP idea that would effectively end the era of employers paying a large portion of their workers' insurance costs and replace it with a federal tax credit to help people buy insurance on their own.
And none of the three has a plan to help cover the uninsured.
Each is running for the GOP nomination in the May 15 primary. One is likely to face Democrat Bob Kerrey — a former U.S. senator and Nebraska governor — in the November election.
Kerrey also has no comprehensive plan, although he opposes the repeal of the health care law and supports its individual mandate. He said the reality is that people without insurance can go to an emergency room knowing their costs will be covered by others. Those people should be required to pay for their care via mandated insurance coverage, Kerrey said.
He also said he favors a universal health care program in which all Americans would be placed in a single health pool. The idea would be to trim administrative costs associated with maintaining several systems, such as Medicare, Medicaid and services for veterans.
Kerrey provided no details on how the system would work or how it would be paid for.
But he said all Americans needed to be covered, especially the working poor who do not qualify for Medicaid but who cannot afford insurance. "Nebraska would be a better place if we could help those families who don't have insurance get it," Kerrey said.
For decades, the nation has been debating — off and on — its health care system. Each presidential election, citizens routinely rank rising health care costs among their most pressing concerns. Businesses also have complained, saying the costs of insurance premiums have made it more difficult for them to compete on a global stage.
But every attempt to reform the system, Republican as well as Democratic, has run into heated opposition. In the 1990s, then-first lady Hillary Clinton was soundly rebuffed when she tried to push a reform package that included a provision requiring all Americans to buy medical insurance. That individual mandate now vociferously opposed by Republicans was first proposed by the conservative Heritage Foundation and once championed by nearly all Republican politicians as a market-based reform.
For years, Republicans have advocated tax credits and incentives for health care.
In 2009, U.S. Rep. Paul Ryan, R-Wis., proposed eliminating tax breaks to businesses that help cover insurance premiums for workers. In its place, Ryan suggested annual tax credits to each American, allowing them to purchase their own insurance on the open market. That plan would have provided credits of $2,300 for individuals and $5,700 for families.
At the time, he said, more businesses were cutting back on health care benefits, and he called the employer-based system a "21st century relic."
Republicans have argued the tax credit idea would drive down costs by requiring Americans to think twice before agreeing to optional medical procedures. The idea is Americans would be much better health care consumers if they had to cover more of those costs — asking questions, for example, before agreeing to a second brain scan.
Bruning hailed the Ryan plan, at the time, as an effort toward an honest discussion on reining in the nation's ballooning budget deficit. He also said he supported Ryan's plan to reform Medicare, which would have provided senior citizens with a basic insurance plan. Senior citizens who wanted better coverage could purchase additional insurance on the open market.
Bruning has declined, however, to say whether he supports Ryan's potential replacement for employer-backed health insurance.
"I'm not going to get into that. I'm just going to say we need to get a market-based approach with coverage across state lines," said Bruning, who as the state's attorney general joined the lawsuit by 28 GOP-led states challenging the health care law. He was in Washington this week for oral arguments before the Supreme Court.
Bruning said there are parts of the health care law that he likes, such as the pre-existing conditions provision, but he stopped short of saying he would support such a measure in Congress.
"We have to make sure that everything we do is mindful of the fact that we have a $15 trillion debt," he said.
Stenberg said he has never "signed off" on Ryan's plans. Like his rivals, he has called for insurance companies to market their products across state lines, tort reform to control malpractice lawsuits and laws making it easier for small businesses to purchase insurance together.
He said such programs would be enough to rein in escalating health care costs, although they might not lower those costs.
"I don't know if we're going to see a dramatic reduction in health care costs. What we need to do is make sure we don't see the substantial increases we have seen over the last couple of years," Stenberg said.
One of Fischer's major arguments against the new health care law is her belief that the final bill was "rammed through" Congress with little discussion or time for careful consideration.
If she were elected to the Senate, she said she would seek a "serious discussion" on how to make health care more affordable and accessible to Americans.
Fischer said she recently met with doctors who told her the federal government needs to change the way it pays physicians who provide services to Medicare and Medicaid patients. Currently doctors are paid for procedures but not consultations, leading some to ask for more tests than necessary, Fischer said.
She also said that she would consider Ryan's plan but that she would not support ending the practice of employers helping to pay their workers' premiums.
"Most businesspeople, if they can afford to do it, believe it's a good benefit for their employees," Fischer said.
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