Gore, Bush health care solutions reflect disparate visions of government's role
WASHINGTON (CNN) -- Although no single issue has dominated the political spotlight during the 2000 presidential race, health care has consistently ranked as a top public concern in most surveys, particularly among the nation's most vocal and active voting bloc -- senior Americans.
And like other points of contention between Democratic nominee Al Gore and Republican rival George W. Bush, the candidates' approaches to solving the nation's most pressing health care needs reflect the deep ideological differences between Democrats and Republicans over the role of the federal government in people's lives.
Universal access to health care coverage all but died as a hotbed issue after the Clinton administration's plan for a government-run system was defeated in Congress in 1994. But Gore and Bush have found plenty of other health care topics to spar over during the general election season, including rival proposals for a so-called patients' bill of rights; prescription drug coverage for seniors; keeping the federal Medicare program solvent; and tax breaks to help offset medical expenses.
The fastest-growing part of most medical bills, prescription drugs, has clearly emerged the hottest of health care issues on the campaign trail, and one that the vice president's camp views as its strongest.
Spending on prescription drugs climbed from $38 billion in 1990 to $91 billion in 1998. It is projected to top $110 billion this year, according to the Health Care Financing Administration, the federal agency that oversees Medicare, Medicaid, and other government health care programs.
The burden of cost has fallen most heavily on older Americans -- many of whom live on fixed incomes -- who account for at least one-third of all drug spending in the United States. Stories of seniors traveling by the busload to Canada to purchase drugs marketed at much lower prices -- and others having to choose between between important medication and necessities such as food and housing -- have grabbed the attention of office-seekers eager to please older constituents likely to voice their frustration at the polls.
Gore beat Bush to the political punch on the issue during the general election season, charging that the pharmaceutical industry was guilty of price-gouging. Stumping across Florida, a key battleground state where the senior vote is more influential than anywhere else in the country, Gore pointed to the fact that drug makers enjoyed profits of 18.6 percent of revenues last year -- nearly four times the median for Fortune 500 companies.
CNN's Brooks Jackson compares the prescription plans proposed by Gore and Bush (09-05-00)
(QuickTime, Real or Windows Media)
Republicans say Gore's health care plan won't work. CNN's Eileen O'Connor explains (08-16-00)
CNN's Eileen O'Connor reports on Bush's efforts to encourage the private sector to come up with cheaper plans targeted to the working poor (08-02-00)
To remedy the problem, Gore has offered a traditional expansion of Medicare to help cover the price of prescription drugs for all senior Americans -- at an estimated cost of $253 billion over 10 years.
Under the plan, Medicare would pick up all the costs of prescription drugs for seniors making less than $12,000 a year and couples making $14,000, roughly 135 percent of the poverty level. Those making more would pay monthly premiums on a sliding scale, with the government picking up half the costs. No senior would pay more than $4,000 per year for drugs, the Gore campaign estimates.
The Gore campaign says the nature of its program is cost-effective, arguing that it would give the government program vast purchasing power and the ability to negotiate deep discounts from drug makers.
"Seniors don't have anyone to negotiate for them," Gore said during a forum with seniors in Tallahassee, Florida, last month.
But critics worry that if the government is directing such purchases, it might limit the formulary, or drugs available to Medicare beneficiaries. Others -- including drug makers themselves -- worry about price controls they say could potentially have harmful effects on the industry and consumers.
"Our concern with Gore plan is two-fold. First it would require a huge new administrative structure to implement. Second, it likely would lead to some sort of price-controls which would stymie research and development," said Richard Coorsh, a spokesman with the Health Insurance Association of America, a Washington, D.C.-based trade association representing major insurance corporations.
Drug benefits for seniors: Who should take the lead?
The Bush campaign has derided the Gore proposals, particularly on prescription drugs, as nationalized medicine. It was a similar theme that successfully derailed the Clinton administration's attempt to enact universal health coverage.
Under pressure to neutralize Gore's presumed advantage on health care -- traditional Democratic turf -- Bush released his own prescription drug plan in early September. Its first order of business is an immediate infusion of $48 billion to the states to cover all the drug costs for seniors earning $11,300 a year or less, and for couples earning $15,200 or less.
But the mainstay of the Bush plan is an ambitious 10-year, $110 billion overhaul of Medicare that the Bush campaign claims will "modernize" the entire program and incrementally break down the bureaucracy which now serves 39 million Americans.
Under the plan, beginning in 2002, the Medicare benefit would pay 25 percent of drug costs for all seniors who earn 175 percent or less of the federal poverty level. All out-of-pocket expenses above $6,000 would be covered for every Medicare beneficiary, the Bush campaign says.
The proposal would also give seniors the option of going outside the traditional Medicare fee-for-service program for health care by offering subsidies for seniors to buy into private insurance plans. Those participating would be required to offer a prescription drug benefit as part of the plan.
Dr. Gail Wilensky, Bush's current health care advisor and former head of HCFA under President Bush, said the differences boil down to choices not available under the Gore plan.
"Under Gov. Bush, traditional Medicare will remain an option, including the ability to get a prescription drug benefit," Wilensky said. In addition, beneficiaries will be offered a "variety of options" in the private market, as well the opportunity to switch plans -- an opportunity not available under the Gore plan.
Critics of the Bush proposal say the downside is that private insurers, particularly health maintenance organizations, will simply pull out of the system if it does not prove cost-effective. Although 6.2 million Medicare beneficiaries are currently enrolled in HMOs, those organizations have dropped hundreds of thousands of other seniors -- particularly in markets where care is more expensive.
"In the Bush plan, seniors don't know what they're going to get, and it can change from year to year. When you're 75 years old, you just want to know that your blood pressure medication is going to paid for next week," said Amanda McCloskey, director of health policy at Families USA, a consumer advocacy group based in Washington, D.C.
McCloskey also expressed concern that the price tag of the Bush proposal doesn't accurately take into account scientific breakthrough and advances in pharmaceuticals and other health care sectors that could send costs skyrocketing over the next decade -- at a time when more and more seniors are living longer, healthier lives.
"Quite frankly, it scares me if we're using that small of a number to both reform the program and add a prescription drug benefit .... I'm not sure you can do it all for that little," she said.
Gore has vowed to strengthen the overhaul Medicare system by establishing a "lock box" to protect $400 billion in program surpluses over the next ten years. "Our opponents have not done that," Gore said last month.
Bush contends that Gore has squandered opportunities to bolster the federal program during his vice presidency: "When it comes to Medicare ... this administration has had seven years to get something done. Seven years, and nothing has happened," Bush told CNN during an August 30 interview.
Gore's populist stump speeches have not spared HMOs from the same sort of broadsides his campaign has fired at the pharmaceutical industry. During his acceptance speech at the Democratic National Convention, he pledged to take on "Big Tobacco, Big Oil, the big polluters, the pharmaceutical companies, the HMOs."
The House and Senate have passed different versions of patients' rights legislation, but significant differences remain over a patient's right to sue his HMO and whether patients in state-regulated HMOs should be included in the final bill.
Gore favors the House legislation, sponsored by Reps. Charles Norwood, R-Georgia, and John Dingell, D-Michigan, which includes broader coverage and lawsuit provisions than its counterpart. The measure also calls for direct access to specialists, and it would protect patients from being penalized for seeking emergency room care without prior HMO approval.
Bush has voiced support for a Republican-backed Senate measure hinges a patient's right to sue an HMO upon the approval of an independent review panel. Unlimited economic damages could be requested, but there would be a cap in compensatory damages of $350,000. The plan would cover 56 million Americans mostly enrolled in self-insured plans not covered by state law.
"Gov. Bush also does not want to undo what states have done. Texas and others have been active in this area, making sure individuals have access to specialists, holding plans accountable under a review," said Wilensky, adding that provisions are in place allowing patients the right to sue HMOs.
The Bush campaign -- which has received roughly $1.5 million in political action committee donations from the insurance industry, compared to about $300,000 for Gore -- has come under fire for supporting a "watered down" plan easy on the HMOs.
Critics say that passage of a patient's bill of right in Texas -- which allows patients to choose their own doctors, appeal denials of care and sue their HMOs under limited circumstances -- came in spite off, not because off, the governor's efforts.
"He has been a compassionate conservative because Democrats in the Texas legislature have put in front of him legislation he couldn't afford not to sign," Democratic State Rep. Glen Maxey recently told CNN. "That gives him compassion."
Maxey said Bush vetoed the original legislation because he opposed allowing patients to sue for punitive damages, but eventually signed on to other parts of the legislation and allowed the rest of it to became law without his signature.
The Texas governor has argued that allowing patients to seek unlimited punitive damages would significantly drive up the cost of health care, and in turn hurt small businesses and private consumers.
Expanding access to insurance
Gore also has vowed to move toward universal health care access through a "step-by-step" process. His plan begins with a $100 million expansion of the federally funded Children's Healthcare Insurance Program (CHIP), available to children whose parents earn too much to qualify for Medicaid but can't afford private health insurance premiums.
Bush also supports additional funding for CHIP, but again insists that states, rather than the federal government, should administer the funds. As governor of Texas, Bush says that he signed legislation that opened enrollment in the Texas program to more than 400,000 children.
The Gore campaign charges that the bureaucratic obstacles in Texas have prevented hundreds of thousands of eligible children from enrolling in both Medicaid and the state CHIP program.
To increase enrollment, the vice president says he will simplify the CHIP application process by eliminating asset tests that sometimes intimidate applicants, allowing families to apply by mail, and requiring states to boost minimum eligibility periods from six months to a year. For families with incomes above the CHIP cap -- currently $41,000 for a family of four -- Gore has offered a 25 percent tax credit to help them buy into private plans.
While both sides have disputed the number of uninsured children in the Lone Star State, the Bush campaign has centered its national proposals on tax incentives designed to help low-income families purchase their own health insurance.
The Bush campaign tax credits up to $2,000 per family will help 18 million Americans buy health insurance -- including between 4 and 5 million who currently lack coverage. The plan has an estimated price tag of $35 billion over five years.
Both candidates support offering small businesses tax credits for employee's health insurance, while Bush has also proposed an additional $5 billion to help expand medical savings accounts.
In addition, the GOP nominee has called for:
---$4.3 billion over five years to expand health care services to rural and inner-city communities
--- $3.6 billion in federal aid to create 1,200 new community and immigrant health centers
--- $500 million in pilot programs to address specific health concerns
Gore has proposed:
--- Offering tax incentives allowing people between 55 and 65 to buy into Medicare, and allowing people with disabilities who return to work to buy into Medicare and Medicaid
--- Doubling federal funding for cancer research efforts
--- Increasing funding to community health centers, public hospitals, and academic medical centers.