For Jesse Shirley, having health insurance can mean the difference between life and death.
The 69-year-old Sandy man has arthritis, high blood pressure and diabetes, for which he is being treated at the Stephen D. Ratcliffe Community Center.
Shirley is lucky - he has Medicare. But as he considers who he will vote for in November's presidential election, he worries that not all of his friends and family members have access to coverage.
Because of their age or income, some of them don't qualify for public health insurance programs. Others can join a plan through their employers but can't afford the high premiums.
"They're talking megabucks for that," Shirley said, waiting in an exam room for his doctor on a recent Friday afternoon.
It's a conundrum faced by about 46 million uninsured Americans. A recent Commonwealth Fund study, however, suggests many more than that are struggling to get the health care they need.
Last year, nearly two-thirds of working-age adults - an estimated 116 million people - either were uninsured for a time, underinsured, had problems paying medical bills or skipped medical care due to the cost. And during the past seven years, the same study found, such problems have crept up the income scale.
Sens. John McCain and Barack Obama agree that at least part of the answer lies in improving health care quality and efficiency.
Republican presidential candidate McCain says he wants to put free market forces to work.
At the core of his strategy is removing the favorable tax treatment employer-sponsored insurance now receives. Workers would be taxed on the value of that benefit.
But he would also create refundable tax credits: $2,500 for individuals and $5,000 for families. Money that taxpayers save through the credits could be used to pay for employer-sponsored insurance or to buy a plan on the individual market - across state lines.
"You're not limited," said Gail Wilensky, a senior health policy adviser to the McCain campaign, "and that will not only give a person more choice, it will put a lot more competitive pressure on the insurance plans in terms of giving consumers benefits they want."
More federal money would also be pumped into states' high-risk insurance pools to cover those who have pre-existing medical conditions that make it difficult for them to get individual policies.
Over time, McCain would tie increases in the tax credits to the consumer price index - not health care inflation, which historically has increased at a higher rate.
Wilensky, who ran the Medicare program during the first Bush administration, said consumers will have to become penny pinchers - one of several ways McCain proposes to slow down health care spending.
"If you tie the credit increases to whatever health care spending is, you just keep pushing out to the future the problems we have now," she said.
But Richard Sperry, a physician and director of the University of Utah's Scott M. Matheson Center for Health Care Studies, questions whether McCain's plan could work.
McCain's tax changes would spur many businesses to drop their plans, Sperry predicts, and the number of people losing coverage would be roughly balanced out by those using their tax savings to buy individual policies.
"The net effect of the McCain plan - at least in the short run - is probably not much one direction or the other," he said. In the long run, however, many experts speculate it could increase the number of the uninsured.
"The fundamental question," Sperry said, "is, can market forces be brought to bear to fix the escalation in health care expenditures and the erosion of health care coverage, or do we need to have some thoughtful intervention by the government?"
Obama's plan, he believes, is a good start in the latter direction. Public health insurance programs would be better funded. Employers would be required to "play or pay," meaning they would have to either offer health insurance to their employees or pay a tax toward a national health plan.
Via a National Health Insurance Exchange, small businesses and individuals without access to public programs or employer-based insurance could enroll in a new public health plan - similar to one federal employees receive - or in approved private plans. Obama would require that every American child have health insurance.
But the plan comes at a cost: between $55 billion and $60 billion a year, said David Cutler, a senior health policy adviser to the Obama campaign. "Over the longer term," he said," it's really going to depend on how fast [other proposed] measures can save money."
Shirley, who plans to cast his vote for Obama, said the Democrat is "trying to help the people who are low-income - which is me - and the middle class."
But James Shell, also a Democrat, said Obama should do more. He thinks what the country really needs is a nationalized health system.
"Basic health care right now is, I think, in a serious, serious crisis," said the 49-year-old, who is on Medicare and Social Security disability insurance. "I think that people should try to pull their weight, but you just can't afford it. Even with Medicare, I can't afford the copayments and everything else. I'm just about to cancel out my Medicare because I can't afford the $96 a month."
Joe Jarvis, a physician who founded the Utah Health Policy Project, said neither candidate's plan would work particularly well in Utah - a state that already touts some of the best health care at the lowest cost in the nation.
"Utah has done well," said Jarvis, who is also a candidate for the Utah House of Representatives. "We don't completely understand why, but we can document that's the case. . . . let the 50 different democracies flourish on this."
