HELENA — When it comes to Republicans' health care agenda at the Legislature, they're not just saying "no" to federal reform — they're also pushing plans to encourage Montanans to buy high-deductible, lower-cost health insurance.
"In most cases, the bills are designed to help the person buying individual coverage on their own," said Rep. Cary Smith, R-Billings, the sponsor of a half-dozen health care bills. "It puts people in charge of their own health care. They have to go out and shop for their health care, so that drives down costs."
Their proposals include state income tax credits and deductions for individuals and businesses that buy low-cost plans, expansion of health savings accounts, getting rid of mandated benefits and allowing health care "ministries," which are religious organization that pool health care costs for members.
Republicans, who control majorities at the Legislature, have advanced most of these proposals through the House on party-line votes. Next up is action in the Senate, where the GOP holds a 28-22 edge.
The Senate also has been passing bills to block or undercut implementation of the federal health reform law in Montana.
Rep. Gary MacLaren, R-Victor and another sponsor of several health care bills, said the federal approach of mandating that all Americans buy health insurance by 2014, and subsidizing the cost for the needy, is unpopular, won't work and is too costly.
Instead, Republicans want to make high-deductible policies more affordable, through various credits and incentives, and thereby make people think twice before seeking routine medical care, because they'll be paying for most of it out-of-pocket.
A high-deductible policy is much cheaper than generous health coverage, but has a "deductible" of up to $10,000. Any medical expenses below that amount and incurred by the person holding the policy are the person's responsibility.
"The idea is to get people at least partially responsible for health care," MacLaren said. "When people can save money if they don't go to the doctor ... they tend to take better care of themselves."
Democrats, who can only sit and watch as Republicans push through their agenda, say the GOP approach is a rehash of policies they've pursued for years, without solving the problem of rising health care costs.
"You can already get high-deductible plans, you can already get tax credits, and health insurance continues to rise every year," said Sen. Mary Caferro, D-Helena. "Why would they work now? It's just silly."
Rep. Chuck Hunter, D-Helena, said high-deductible plans and tax-deductible health savings accounts work for people of means who have disposable income, which they can spend on insurance and moderate health-care costs.
But for the tens of thousands of Montanans without insurance or unable to afford regular health care, the GOP solution is no solution at all, he said.
"I don't think it speaks to the broad need of the huge amounts of Montanans who are in need of some affordable care," said Hunter, a former state health official and lobbyist for low-cost health clinics.
Republicans also have been voting to cut or scale back funding for public-health programs, such as family planning money for clinics that serve many low-income women and Healthy Montana Kids, a state insurance plan for kids in low- and moderate-income families.
Republicans say they're offering free market reforms that help people buy insurance in the private market and reduce costs.
Their major proposals include:
• State income tax credits or deductions for individuals who buy private insurance, and for businesses that help workers finance high-deductible policies.
• Increasing the amount of money that can be deposited, tax-free, in a health savings account.
• Shielding medical providers from liability, to reduce malpractice-insurance and "defensive medicine" costs.
• Creation of health care ministries, which are religious organizations where members share health-care costs. A tax deduction for contributions to the ministry would be created.
Smith said if more Montanans move to high-deductible policies, they'll pay less for insurance, reduce costs for business and reduce demand for medical services.
Health insurance should be more like auto insurance, he said, covering big accidents, rather than routine maintenance.
And if someone chooses not to have insurance and incurs a huge medical bill, they should have to pay for it, he said: "I'd have them paying it off for the rest of their life. Why should somebody get a benefit for being irresponsible?"
State Auditor and Insurance Commissioner Monica Lindeen, a Democrat, said the GOP plan simply doesn't add up.
High-deductible plans already are widely available in Montana, and offering relatively meager tax credits and deductions to reduce their cost won't instantly turn them into a good deal, she said.
"If those high-deductible plans had benefits that covered what people needed, people would be buying them," Lindeen said. "I don't know where (Republicans) get the idea that high-deductible plans will reduce costs. I've never seen any data that show that."
Lindeen has been pushing bills to implement federal law, including an Internet marketplace for insurance, saying that approach might actually do some good.
Hunter said Democrats see some problems with the federal law, too, but that its basic premise — create a minimum package of health benefits and subsidize the cost for those who have trouble affording it — is a good one.
The Montana GOP plans will help only a limited number of people, he said.
Smith acknowledges that Republican plans aren't a silver bullet for solving health care — but that Republicans are united in their belief that the federal law will not work, so they're coming up with other ideas.
"Some of (our) stuff may work," he said. "Some of it may not. But that's kind of the chance you take when you reform things. We're not just saying 'no.' We've got some alternatives. Are they guaranteed solutions? I don't know."