This is part of a series of stories on issues in the local congressional races, leading up to the election next month. This story focuses on health care. Future stories will look at Social Security, Medicare, federal spending and defense cuts.
U.S. Sen. Bob Casey is the Democrat running for re-election. Tom Smith is the Republican who wants his job. President Barack Obama's national health care reform law highlights their divide perfectly.
Mr. Casey proudly voted for the law; Mr. Smith wants to repeal it at all costs.
"It was the right vote," Mr. Casey said.
"I think it's the most intrusive invasion of personal rights that I've seen in my lifetime," Mr. Smith said.
As the two crisscross the state campaigning, the Patient Protection and Affordable Care Act, also known as Obamacare, looms as a major issue.
Then, there's Rayburn Smith, the Libertarian Party candidate, who says he would have opposed the law, and has his own novel idea of what to do about ensuring health care coverage for all Americans.
Signed into law by Mr. Obama on March 23, 2010, Obamacare aimed to expand health care coverage to an estimated 32 million uninsured Americans, but it comes with plenty of other provisions, some likeable, some quite controversial.
Topping the list of the controversial: a requirement that everyone have health insurance and penalties for those who don't, a mandate upheld by the Supreme Court in June.
Among the favorites: elimination of three-quarters of the gap in senior citizen prescription drug coverage by 2020, a prohibition on insurance companies denying anyone coverage for pre-existing conditions and letting children stay on their parent's health insurance plans until age 26.
The law also fines companies with more than 50 employees $2,000 a year per worker if they don't provide health insurance, though the first 30 employees are exempted; provides a tax credit to many small employers with no more than 25 employees; increases the threshold for deducting medical expenses on tax returns by a third, making deductions less likely; and cuts $716 billion in subsidies to private Medicare Advantage plans and other health care providers to help pay for it.
Its cost, estimated by the Congressional Budget Office, is about $1.76 trillion spread over 2012 to 2022, but the CBO also says it would trim the federal deficit by $124 billion, a figure Republicans hotly dispute.
Candidate Tom Smith argues the law would turn over "one-sixth of the economy to the federal government," despite its provisions that its main, intended purpose - coverage for the uninsured - would happen through state-sponsored insurance exchanges involving private insurance plans.
"It's going to be controlled (by the government)," Mr. Smith said. "You're going to have an unelected board there making some final decisions. The free enterprise system is the best place for our health care, not in the hands of the federal government."
The "unelected board" is the 15-member Independent Payment Advisory Board, which is charged with ways of slowing Medicare's growth.
The law expressly forbids the board from rationing health care. Any recommended changes to Medicare go before Congress, which may reject them with a vote of three-fifths of its members.
"I think it's very clear from the language in the bill ... that they cannot make benefit determinations," Mr. Casey said. "They can make assessments of where things are, they can make recommendations. They cannot supplant the role that Congress plays if Congress wants to make a change in the program. It's as simple as that. To add interpretation that somehow this entity is going to impact people's benefits, it's a lie and they know it's a lie."
Mr. Smith said he opposes requiring people to buy health insurance, although that means the uninsured will seek free coverage that hospitals, doctors and people who have insurance will have to absorb.
"You can address that, but you don't change the best health care system in the world," Mr. Smith said. "You're talking (about) every bit of control by the federal government."
Mr. Smith said he favors the bill's pre-existing condition and age 26 coverage provisions. But its "20 new taxes" and $716 billion cut to Medicare Advantage plans reflect "a bad piece of legislation," he said.
"Anything 2,700 pages long has to give us a moment of pause and we're now seeing what's in it," he said. "We don't need a complete overhaul of the health care system. What we need are some minor adjustments."
He favors tort reform that limits medical malpractice awards, which raise malpractice insurance premiums.
"That's driving up the price of health care for all of us," he said. "I'm not saying write a new law, just tinker with what needs to be done."
The best way to deal with the uninsured is to "grow the economy" so more people have jobs and the health insurance that comes with a job, he said.
He also favors allowing small businesses to band together in pools to find cheaper health insurance coverage and allowing health insurers to offer insurance across state lines.
"There's nothing like good competition," Mr. Smith said. "That'll do more to hold down the price than anything else."
He said the law is discouraging an economic recovery because businesses fear hiring anyone new before they understand its effects.
"We can't risk hiring," said Mr. Smith, a former coal mining company owner who farms and owns a trucking company.
He notes Mr. Casey never talks about the law.
"Sen. Casey has to run against his voting record and I wouldn't talk about it either," he said.
Mr. Casey said he knows the bill needs tweaking, which is why he is now in favor of eliminating a fee on medical devices.
"We're trying to make changes that make sense, but what we can't do is repeal legislation that will take away protections for kids with pre-existing conditions," he said.
Repeal will also force many senior citizens to pay more for prescription drugs and letting insurance companies rule health care.
"Insurance companies, without this legislation, can pretty much do anything they want," he said. "They can deny you coverage, they can cut you off, they can put in lifetime limits, annual limits (on coverage). Talk about disproportionate power against the interests of families."
Mr. Casey said the ideas that Mr. Smith says foster competition are worth considering if they make sense, but Republicans have yet to come up with a comprehensive solution.
"To constantly invent theories or give projections which are questionable at best, it's all geared towards this idea to repeal it and they have no plans to replace it," he said. "They barely whisper the word replace and I don't hear a word from them."
He said Republicans ignored health care's rising costs and the uninsured problem for years.
"You look at the last quarter century and where have they been on this issue?" he asked. "They had the White House for a long time, they had control of the House and Senate at various times. They never took it on because I just don't think it's a priority for them."
Ending the coverage mandate won't work because the money raised by that makes possible pre-existing condition coverage, he said.
"And then they (Republicans) turn around in the same sentence and say 'We're against the mandate,'" he said. "They known you can't pay for those protections (without the mandate) ... If you don't have any coverage and you've got a pre-existing condition and you're seeking coverage, Mitt Romney and Tom Smith and the whole crowd don't give you any help. So you are on your own and the child is on their own, too."
Mr. Casey also highlighted other elements of his health care record as senator. They include getting Congress to pass provisions that encourage the education of more pediatricians, obtaining $250 million to help vulnerable pregnant women and $1.25 billion for a tax credit to encourage adoption and the reauthorization of the Children's Health Insurance Program.
Rayburn Smith said he would have voted against Obamacare because of the mandate to buy coverage.
"I don't think we should have penalties for not complying and not buying insurance," he said.
He likes the pre-existing conditions and age 26 coverage requirements and its rewards to doctors who follow "best practices."
But he wants to replace it with a federal cooperative that entails citizens buying stock, paying premiums and controlling coverage through a board elected by stockholders.
"I even thought of tying a national lottery into it to fund it" like the Pennsylvania Lottery funds senior citizens.
A plan so large would offer more affordable rates, he said.
Contact the writer: bkrawczeniuk@timesshamrock.com