The New Physician
Not ready to tackle real solutions to the current U.S. health-care crisis, Bush and Gore stick to simple and surprisingly similar health proposals.
Evidence that politicians on both sides are beginning to recover from the 1993 health-care debacle runs rampant in this election year. Health-care issues—a political pariah since the Clinton health plan fell apart in 1994—has actually become a headlining issue in the race for the White House.
The two candidates with any realistic chance at winning, Texas Gov. George W. Bush and Vice President Al Gore, often sound like they are speaking the same language when it comes to dealing with the 44 million uninsured Americans, a Medicare prescription drug plan and a patients’ bill of rights. But their plans are relatively narrow and uninspired, according to many health-care policy wonks. The differences lie primarily in the ideological discord the two candidates have about how to pay for such changes.
But just as Ross Perot shook up the 1992 election with a call for better economic policies, Green Party candidate Ralph Nader is forcing candidates and voters to consider the alternative—a single-payer, universal health-care plan that would turn the current system inside out.
If Vice President Al Gore had his way, the year 2005 would bring two things: A cold January day would find him reciting the presidential oath of office marking the beginning of his second term, and 12 million previously uninsured Americans would finally have adequate health care.
Yes, Gore has plans, but so does his Republican rival, Texas Gov. George W. Bush. The uninsured have made their way to his agenda as well. However, the GOP leader’s platform calls for more modest measures by most analysts’ accounts—aides say his health-care policies could help an estimated 4.5 million previously uninsured folks.
And while 12 million and even 4.5 million seem like a lot of people for a policy to touch given some of the pork-barrel spending the federal government is infamous for, many analysts say the two candidates are not going far enough. “What about the rest of the 44 million uninsured?” they ask.
COME TOGETHER, EVERYBODY
The mothers of Gore and Bush must be pretty proud right about now. That sharing idea from childhood definitely sunk in. So much so, the 2000 presidential election has been marked not so much by where the candidates differ, but by where they are in agreement. And when it comes to health care, telling the two apart can be confusing at times.
“I think it’s interesting what they’re in agreement on,” says Greg Scandlen, a senior fellow at the National Center for Policy Analysis. Scandlen notes the two major party candidates agree on many issues: refunding tax credits for private insurance, expanding the State Children’s Health Insurance Program (CHIP) and passing a patients’ bill of rights and a Medicare prescription drug benefit.
Both candidates also call for more support of community health centers—Bush says to the tune of $3.6 billion over five years, and Gore to $40 billion over 10 years for “community health centers, public hospitals and other safety-net providers.”
Both of the tax credit plans are intended to help the 9 percent of the population privately purchasing its own insurance and the 16 percent of the uninsured population. The only difference between the two is in the details.
Bush’s plan would provide up to a $1,000 tax credit to each individual ineligible for public programs or employer-based coverage. Families would receive up to $2,000. The money could cover up to 90 percent of the total cost of the insurance premium, and the credit would increase as the recipient’s income decreases.
Gore’s plan, on the other hand, would provide a tax credit equal to 25 percent of the premium cost to individuals and families who lack access to employer-sponsored health insurance. Gore also plans to extend this credit to small businesses in an attempt to make it easier for them to offer insurance to their employees, says Dr. Richard Boxer, a health policy and family medicine professor at the University of Wisconsin and the Medical College of Wisconsin. Boxer, also a practicing urologist in Milwaukee, says that of the three major health-care specialists on each candidate’s policy team, he is the only physician. The small-business program would affect employees at companies with 50 or fewer workers.
The two tax plans are also alike in that they share the same criticism from policy analysts. Like much of the Republican and Democratic health policies, the proposed tax credits don’t go far enough to fully reform the U.S. health system, analysts say.
A tax credit is only going to be effective if you can afford the balance, says Jason Lee, a senior research manager at the Academy for Health Services Research and Health Policy. With privately purchased family insurance averaging a $5,000 price tag, the problem remains: Where does the other $3,000 come from?
Coming up with even small amounts of money for coverage is difficult for many uninsured, analysts say. Lee points out that many of them already have access to health care through their employers, but they can’t afford the co-payments. A Center for Studying Health System Change report found 20 percent of the nation’s uninsured decline employer-sponsored coverage for this reason.
“The problem is not necessarily the poor, it’s the near poor,” Lee says.
Dr. Bob Graham, former executive vice president of the American Academy of Family Physicians, says tax credits present three problems. One, he agrees with other analysts that the credits don’t go far enough. Two, he questions the intelligence of a plan that requires individuals to purchase their own insurance. “Who will sell it to you, and who will sell it to you next year?” he asks, adding that in a market-based system, insurance companies have every right to drop your coverage or hike your premiums from one year to the next if you become a liability.
Graham’s third problem with tax credits is one of timing. He says a credit comes back at the end of the tax year, while a premium most likely has to be paid in January. “Where do I get the $2,000 in January?” he asks.
Perhaps expecting such criticism, the Bush proposal does include a policy allowing credits to be advanced to the insurance company when the premiums are due. The issue here then becomes one of logistics and timing.
Still, Scandlen says it would take a credit of about 40 percent to make a difference to the uninsured—something he supports because it would relieve many people from employer-based insurance.
“I’d be interested in leveling the playing field between individual coverage and employer-based coverage,” he says. “Employers really don’t know about insurance.” However, Scandlen knows this is wishful thinking. “Forty percent is a lot. It’s a lot of money. It’s a big loss to the Treasury.”
As it is, the Bush tax credits will cost an estimated $34.7 billion over the next five years. Bush’s office refused repeated requests by The New Physician to explain where the money would come from.
Gore’s entire health policy will cost $157 billion over 10 years, and Boxer says the money will come entirely from projected budget surpluses.
CHIPPING AWAY PROBLEMS WITH CHIP
CHIP found its way into the Republican and Democratic health-care agendas as well. Both candidates plan to expand the 3-year-old program, but they do differ on how to go about it.
CHIP, which enables states to insure children from working families whose incomes are too high to qualify for Medicaid but too low to afford private health insurance, currently cuts off children whose families have incomes 50 percent above Medicaid cutoffs or 200 percent above the federal poverty line, whichever is higher. States are permitted to provide CHIP coverage through Medicaid expansions, a separate state program, or a combination of both.
Gore’s plan is twofold: He wants to insure all children by 2004 while opening CHIP to some of their parents. “We [already] insure every person over 65, but we don’t insure the children. That, to me, is screwy priorities,” Boxer says. To combat this inequality, “the vice president wants to ensure every child has access to health care,” he says. “[But] that doesn’t mean the government will provide health insurance to every child.”
Instead, it means Gore will provide states with the means to expand CHIP to all children in families with incomes up to 250 percent of the federal poverty line.
A Gore administration would also provide states with a series of incentives to get more kids on the rolls, a sort of carrot-and-stick approach he hopes will bring all qualifying children into the program. For those who don’t qualify, Gore will allow them to buy into the program, which will then qualify them for his 25 percent tax credit.
Boxer says Gore wants to change little things in CHIP as well, like creating a system in which school lunch programs can share information with the U.S. Department of Health and Human Services to help identify potential CHIP applicants. Currently lunch programs can’t share their information with other federal government programs. “They’ll make it just plain easier,” Boxer says, adding that the Texas legislature recently complained about the restrictive rules in the state’s CHIP program.
The Gore camp estimates 5 million previously uninsured children would be eligible for CHIP under his plan. About 85 percent of them are attached to 7 million uninsured parents, and the vice president says he’ll expand CHIP to them as well. “Once you insure the parents, they’ll be more likely to bring their kids in [for care],” Boxer says.
Bush’s plan differs in that the Texas governor would turn CHIP into a traditional block grant program, which he says gives states more flexibility to design a program best fitting their needs.
Hold on a minute, says Dr. Bruce Vladeck, the former head of the U.S. Health Care Financing Administration. “In most states [CHIP doesn’t] cover nearly enough people. There’s no evidence that the states are going to do anything with a block grant,” he says.
Vladeck, a universal health-care supporter who believes employers should be mandated to offer insurance, says he would rather see children given a health insurance card at birth than have them rely on a government program.
Graham agrees that by focusing on CHIP, the candidates are wasting their precious policy time. “It’s already struggling,” he says.
And it’s floundering, Scandlen says, because while CHIP enjoys popular support in Congress, it’s not lauded at the grass-roots level. “It makes you wonder,” he says, “if it’s such an unsuccessful program, why bother expanding it?” But in this case, he says, block grants make more sense, because with such a fledgling program, no one really knows what is the best approach to making it more successful.
DISPLAYING TRUE PARTY COLORS
Regardless of the approach to fixing CHIP and the similarities of their agendas, the Gore and Bush plans illustrate the two parties’ ideological differences.
Expanding CHIP “tends to be the Democratic orientation to this program…,” Lee says, “while Republicans say the federal government has not given the states the flexibility needed” to solve CHIP’s problems. It’s the classic big government vs. states’ independence argument that has dominated American two-party politics since the first publication of the Federalist Papers.
Robert Blendon, a Harvard University professor of health policy and political analysis, says the differences are simple: “Bush believes you should have a plan without a lot of government influence.” He points to Bush’s pledge to expand the pilot Medical Savings Accounts (MSA) program, which Gore opposes.
Blendon says Gore opposes MSAs and a block grant system for CHIP because the vice president believes a government-run plan is a better way to get more people insured.
Boxer agrees with Blendon’s assumption, saying that it’s true Gore would not expand MSAs because he believes they are “for the healthy and the wealthy” and not the uninsured.
Perhaps Donald Moran, a Bush consultant, sums up the Republican view best when he told an audience in June that “private market solutions are better than governmental solutions.”
Despite their differences, most analysts agree that neither Bush nor Gore has made an effort to make a real, definable impact with their health-care policies. “They have essentially made a decision in this campaign not to deal with real health-care issues,” Graham says. He would like to see more candidates like the Green Party’s Ralph Nader, who has put forth a pledge for single-payer, universal health care. “[We need] universal health care from the cradle through the nursing home, with a single-payer system like Canada’s,” Nader told POZ in May. “In the U.S., 24 cents of every dollar spent on health care goes to administrative costs, but the Canadians spend only 11 cents. The difference could pay for covering the 47 million Americans who now have no health insurance.”
Don’t expect Gore and Bush to take up his mantra. “I think that what they have both done is decide that universal health care is not a defining issue,” Graham says. “Each candidate has said [in effect], ‘I’m just not going to take it on.’”
But, don’t lay all the blame on the candidates, Blendon says. It’s also the fault of the American public. “It’s possible to insure every American, if you want to pay for it,” he says, and adds that voters aren’t ready to do this yet. “The mood [of the people] is sort of incremental. Voters are not looking for a big solution.” What the voters are looking for, he says, are little changes to a number of government policies—so they actually only expect minute changes on the health-care front.
They certainly aren’t looking for Nader’s solution, Lee says. “[Universal health care] sounds like socialized medicine to most people,” he says. “People in this country are very cautious when it comes to health care.”
Blendon says it will take three or four more years until voters are ready to discuss wider-reaching solutions. Even Nader himself seems to agree. He recently told the Sacramento Bee he thinks “we are in a real transition period here that gives us a great opportunity to recast our health-care system into nonprofit mode and expand universal health care.”
Many analysts agree that Nader has got the health-care reform ball rolling. “If you have a [candidate from a] third party, and he gets votes and the audience applauds, it can have an effect on future elections,” Blendon says. “Then parties start to take notice.”
But for now, it looks as if candidates who propose slow and steady change will win votes. So without attempts at big solutions like the 1993 Clinton plan, which proved unobtainable in Congress, the current menu of health-care policies are all politically obtainable, analysts say.
“I think what either one of them is proposing is completely doable,” Scandlen says, adding, “I think they can do a lot more—and they might—once they get into office.”
Editor’s note: Despite repeated requests, both Green Party candidate Ralph Nader and Republican candidate George W. Bush failed to respond to The New Physician for this article. Nader’s staff did forward some statements on health care for us to use. For more information about the candidates and their positions, see their Web sites, at www. georgewbush.com, www.algore2000.com and www.votenader. com.
Jennifer Zeigler is a senior writer with The New Physician.