Today's Washington Post has in-depth looks at the two candidates' health reform plans. The piece on Obama focuses on his plan's similarities to Massachusett's experience with reform and the one on McCain's plan draws comparisons to Minnesota's use of high risk pools to try to cover some of the state's "medically uninsurable."

We agree that Minnesota's pool works better than similar programs in other states, and if you are going to model a national plan on one state's experience ,then Minnesota is probably the place to start. Post reporter Amy Goldstein does point out some of the problems that other states have encountered in their pools, including underfunding, long waiting lists, and very high costs for beneficiaries:

Its [Minnesota's pool] finances are strained and getting worse, but less so than in other states. California's high-risk pool is so strapped that it put a limit on enrollment this year and lowered the maximum it would spend on anyone's treatment. Tennessee's pool has had to eliminate low-income subsidies for new members. Florida's pool has not let in anyone since 1991.

Just yesterday, the Los Angeles Times reported on the latest struggles of the California pool, which is serving fewer people today than it did a decade ago. It's covering about 13,000 people, or 2 percent of those deemed "uninsurable," and it will cover $75,000 of medical costs in any single year.

So, state high risk pools are only going so far already in providing a safety net to the "uninsurable." To expect them to pick up too much of the burden of our national health care crisis may be asking an awful lot. State high risk pools nationwide only cover a total of about 200,000 people—and we have 46 million uninsured (not all of whom, of course, would or should qualify as "uninsurable" under high risk pool eligibility criteria). Given the economy and the rising jobless rate, we're pretty sure the number of uninsured and underinsured is rising, not falling. We asked our New America health policy colleague Sarah Axeen, who has done some work on the economics of high risk pools, whether the numbers are likely to add up. McCain's adviser had been talking about funding levels from $7 to $10 billion, and more recently said that could be doubled.

Chances are, that's short of what's needed. If you accept the McCain estimate that the risk pools would cover 5 million lives, it would cost a tad over $20 billion, a bit more than McCain's revised uppermost number. But that's assuming that those five million could all pay the premiums which are way higher than private insurance (1.25 to two times higher) as well as the often hefty out-of-pocket expenses that people with serious health conditions face.

Now let's check the scenario under the Lewin study figures on likely rates of uninsured people under McCain's plan. That study assumes that that about 21 million people would be able to get insurance under McCain's reforms. But about 25.5 million would still be uninsured, and those would generally be the ones who would be the hard to insure, the older and/or sicker ones who can't find coverage today and who many nonpartisan analysts believe would still have trouble finding coverage in McCain's scenario.

On average, Sarah tells us, in current high risk pools it costs $4125 per enrollee for a state to subsidize an individual's coverage. This is assuming that the enrollee can pay the full cost of the high risk pool premiums—remember that's about 120-200 percent of normal premiums. At the average subsidy cost, it would require approximately $105.2 billion just to subsidize their coverage, assuming they didn't need additional subsidies to afford coverage in a high risk pool. So, while high risk pools are a possible solution or piece of the solution to covering the uninsured, the cost is quite high to state and federal governments. Concentrating that many people into high risk pools, instead of spreading the risk among larger swathes of the insured population, is not the most-cost effective way to go. And we'll still have a lot of uninsured people.

After all even Lynn Gruber, who has run the Minnesota program for 18 years says these pools should be a state-based stop-gap until the country as a whole has a health care solution. "It's not a panacea... . . We need to be moving in the direction of universal coverage," she told the Post. "No one should be rejected because of their health conditions. Our federal government has failed us . . . if we are still here in five or 10 years."