Will health care decide who goes to the White House?

Managed Care 2000

Will health care decide who goes to the White House?

The candidates are talking about it, and voters are listening. It isn't clear, though, that the complex issues of Medicare, patients' rights, and the uninsured will remain No.1 in November.

By Michael Pretzer
Washington Editor

In the wintry days before the New Hampshire presidential primary, Vice President Al Gore tried to use the issue of health care to distinguish his candidacy. At one town meeting, he spent a half-hour answering one voter's question about the topic.

Gore's focus on health care makes sense, since much of the electorate apparently agrees that the system is broken and needs fixing. But the issue is too complex and unwieldy for it to be a rallying point. In New Hampshire, for example, most voters were unaware of or became confused about Gore's views. In a nationwide survey released in mid-January by the Kaiser Family Foundation, half of registered Democrats said they didn't know the difference between his plan for the uninsured and former contender Bill Bradley's plan, and 31 percent erroneously thought Gore's program was the more comprehensive.

Still, health care remains a significant Campaign 2000 topic. It will be "a critical factor," says Drew E. Altman, president of the Kaiser Family Foundation.

"No candidate can be elected without a solid commitment to addressing critical health care issues," adds Thomas R. Reardon, president of the American Medical Association.

Public opinion polls back them up. The Kaiser survey placed health care second—a single percentage point behind education—as the issue most on the minds of voters. Other polls put it at the top.

To make sure public interest doesn't flag, the AMA has been making what it terms a "national house call." In many of the states with primaries, Reardon and other high-ranking AMA officers, along with local physicians, have been barnstorming in a leased Winnebago. "We've talked to newspaper editorial boards and done TV interviews to keep medical issues visible," explains Reardon.

In addition to fanning the flames of public opinion, the AMA has challenged both presidential contenders to answer the following six questions: Do you support a meaningful patients' bill of rights? Do you support health insurance coverage for all Americans? Do you have a plan to stabilize Medicare so it will be viable in the future? Do you believe physicians, not insurance plans, should determine medically necessary care? Do you believe HMOs should be held accountable for treatment decisions? Do you support tax reforms to make health insurance more affordable? One negative answer ought to mean thumbs down on the candidate, says Reardon.

Other organizations also have been working to keep health care front and center. The American College of Physicians-American Society of Internal Medicine, for instance, has been running newspaper advertisements in primary states to focus voters on the problem of the uninsured. "No health insurance? It's enough to make you sick," the ads say. And the ACP-ASIM has issued its own demand of presidential candidates: Develop a policy that leads toward universal coverage.

The issues

Today, health care is not a single issue, but rather a collection of problems and concerns. Three stand out: the plight of the uninsured, the future of Medicare, and patients' rights in the era of managed care. Of the three, the matter of the uninsured has the most resonance at the moment.

The entire populace, it seems, is talking about the approximately 44 million Americans who are without health insurance. Democrats and Republicans, conservatives and liberals. The business-minded Health Insurance Association of America and the consumer-oriented Families USA. The American Association of Health Plans and the AMA. The situation is a moral outrage, they say. It's a failure of politics.

Everyone wants the problem solved, but nobody has a solution. Congress has scarcely begun to grapple with the issue, and public opinion is divided. Twenty-five percent of registered voters want to require all businesses to offer insurance to employees; 21 percent want to expand government programs such as Medicaid, 20 percent want to create subsidies or tax incentives, and 17 percent want to establish a new federal program, according to the Kaiser study. Thirty-nine percent say they're willing to shoulder a tax hike to deal with the problem, while 43 percent prefer that the problem be addressed without raising taxes.

As a problem in search of a creative solution, the uninsured miasma gives each candidate an opportunity to portray himself as a visionary. The Medicare issue, on the other hand, allows candidates to demonstrate their political skills. There's general agreement that baby boomers will put a strain on Medicare when they start to retire a few years from now. But every proposal to bolster the program seems to incite some segment of society—doctors, hospitals, the insurance industry, nursing homes, and senior citizens themselves.

Plus, there's no consensus on how much Medicare needs to be changed—a tweak or an overhaul? In the Kaiser survey, about half the respondents said only minor adjustments are necessary and about half favored wholesale restructuring. Either way, shepherding a Medicare reform program through Congress will require a deft political touch.

And what about the issue of patients' rights? If nothing else, it lets the candidates display their grasp of the obvious. The debate on Capitol Hill during the past couple of years has evolved in such a way that by now it's nearly impossible—at least publicly—to oppose patient protection legislation. The public favors it overwhelmingly. Seventy-five percent of Democratic voters and 68 percent of Republican voters support passage of a patient protection bill, according to the Kaiser survey.

The candidates

Where do Gore and Texas Gov. George W. Bush stand on the issues of the uninsured, Medicare reform, and patients' rights? And what are their views on matters such as medical liability, confidentiality of medical records, physician unions, and prescription drugs for senior citizens? As they trudge through the primary season and toward the Republican and Democratic nominating conventions in mid-summer, are they revealing themselves to be forward-looking problem solvers—or politicians-as-usual?

George W. Bush has yet to issue a broad national health care policy. Instead, he's been pointing to his record of health care reform in Texas. That record, according to Kimble R. Ross, a vice president for public policy at the Texas Medical Association, is a notable accomplishment. "On the governor's watch, the Texas legislature—despite its hard-nosed, pro-business conservatism—enacted an impressive string of health care reforms that are the envy of every state legislature in the country," Ross writes in Roll Call, a Capitol Hill newspaper.

In 1995, Bush supported medical liability reform that, according to Ross, has caused a drop in the number of frivolous lawsuits against physicians in Texas. Between 1995 and 1999, patient protection legislation endorsed by the governor was passed. The new laws let managed care patients appeal treatment decisions to an independent panel and in some cases to a court, require coverage of emergency room care, prohibit gag clauses in physicians' contracts, and provide direct access to obstetrician-gynecologists. A measure that gives patients the right to sue HMOs passed despite Bush's opposition, and it became law without his signature.

On a national level, Bush supports more Medicare options coming from the private sector, a prescription drug benefit for needy seniors, MSAs as a viable way to pay for health care, and a federal patient protection act so long as it doesn't pre-empt state protection acts.

The job Bush did in Texas has been good enough to convince the sole physician who is a US senator to make an endorsement. "Gov. Bush's message of compassionate conservatism is the future of our party," says thoracic surgeon Bill Frist, R-TN. "I'll do everything I can to see that he carries Tennessee and becomes the next president."

That, of course, would be quite an accomplishment considering that his opponent in November will be Tennessee Democrat Al Gore.

Al Gore, Washington's foremost policy wonk, is more specific about how he would improve the nation's health care system. His agenda consists of five "bold steps." One of them—reducing the number of people without health care coverage—has seven elements:

• By 2005, extend coverage to all children by loosening the eligibility requirements of the Children's Health Insurance Program, letting noneligible, low-income families buy CHIP coverage for their children, and offering incentives to get more eligible children into the program. (More than 11 million children are currently uninsured, according to Gore.)

• Allow parents of CHIP-eligible children to be included in the program.

• Let Americans between 55 and 65 buy into Medicare under some circumstances—a policy advocated by President Clinton.

• Permit working disabled individuals who have lost their health insurance to buy into Medicare or Medicaid—another Clinton proposal.

• Give small businesses that join a purchasing coalition a tax credit to induce them to provide health insurance to their employees.

• Give a tax credit to individuals who purchase their own health insurance.

• Strengthen health centers, hospitals, and other institutions that provide health care to the uninsured.

Gore's other four steps:

• Reform Medicare so that the projected budget surplus can be used to "keep the program solvent," so that needy seniors have a prescription drug benefit, and so that financially strapped individuals can get support for long-term care.

• Pass patient protection legislation that keeps medical records confidential, and that puts "doctors and patients in charge, not HMOs and insurance companies."

• Promote preventive medicine and systems that measure the quality of care.

• Support biomedical research while protecting individuals against "genetic discrimination."

Perhaps sensing the growing support for Medicare coverage of prescription drugs, Gore also has proposed what he calls MediCoverage. This plan would offer an optional, no-deductible drug benefit that pays for 50 percent of costs up to $5,000. It also includes "catastrophic" coverage, which would pay for all drugs after a senior runs up $4,000 in out-of-pocket expenses, and total coverage of drugs for low-income Medicare beneficiaries.

Gore's incremental march toward universal coverage—"we have learned that we cannot overhaul the system in one fell swoop"—has won him a good measure of support, including that of a least one well-known doctor. "His approach to expanding health care is the best way to achieve the ultimate goal of universal care for all Americans," says internist Howard Dean, Democratic governor of Vermont. "People who really know health care support Al Gore's vision."

The Bradley and McCain factors

The vice president's plan, however, has come under criticism—by neophytes, presumably. Some say it does too little. "Gore appears to have concluded that substantially expanding health insurance coverage is not a major national priority," write John Holahan and Len M. Nichols, senior analysts at the Urban Institute, a Washington, DC, research organization. "All of his measures, taken together, would expand coverage only modestly."

So the question becomes, will Gore embrace more of former opponent Bill Bradley's health care vision—known to be more expensive but more comprehensive than Gore's own—in order to preserve support among voters for whom health care is the most important election issue?

The companion question may be even more crucial to Bush's election fate. Will the governor commandeer any of McCain's modest health care agenda? It's said that Bush cannot win in November unless his candidacy can rally renegade McCain supporters, 40 percent of whom have said they prefer Gore, the Democrat, to Bush.

Here's a look at Bradley's and McCain's approaches to health care:

Bradley, even more than Gore, would concentrate on the issue of the uninsured. "Good health is a blessing," the onetime US senator has said. "But good health care is a right."

Bradley envisioned universal coverage as lifetime protection, and he would have promoted a different approach for each stage of life, from infancy to old age. "The problems at each stage are different, and solutions must fit the problems," he explained

Bradley proposed a three-stage program for the uninsured:

• Stage 1. Require that all children be insured. If coverage isn't available through a parent's policy, it may be obtained through one of the private insurance plans participating in the Federal Employees Health Benefits Program. (FEHBP currently provides health insurance for about 9 million current and former government workers and their families.) Full and partial subsidies and tax breaks would be available for low-income families, and health insurance premiums would be tax-deductible regardless of income.

• Stage 2. Allow all Americans 19 through 64 to get health insurance through an FEHBP plan. Again, the government would provide subsidies and tax breaks to low-income individuals and make insurance premiums tax-deductible for everyone. It would also fully subsidize prenatal care for poor women.

• Stage 3. Enhance Medicare by adding a prescription drug option; beneficiaries who sign on would pay a $500 deductible and a $25 per month premium, and be responsible for a 25 percent copay. Bradley would also have offered a new program of coordinated home care—similar to that of an ongoing Medicare demonstration project—that would wrap together social and medical services.

Although Bradley estimated that this program would have cost between $50 billion and $65 billion a year, he said it would have ensured that 95 percent of Americans have health coverage. "[My program] should be viewed as a starting point, not a final plan," he noted. "Making health care available to all will not be easy. But the difficulty is a challenge, not a reason to avoid engagement."

Bradley also called for a patients' bill of rights and an effort to shore up the nation's public health system. And though he had no Howard Dean endorsement, he talked a talk physicians could appreciate. "In 1996, hospitals and doctors spent $30 billion to $50 billion trying to get paid," he said, "and insurance companies spent another $30 billion to $50 billion trying not to pay. Many doctors spend two to three hours a day on the phone, looking for approval to provide care, explaining a decision, or inquiring about reimbursement. It's ridiculous. Common sense and technology can change this."

John McCain had no sweeping scheme to extend health care coverage to the uninsured, but he had a number of proposals that taken together somewhat resemble a reform plan. Noting that health care is among the most pressing issues affecting the American family, he said, "We must begin by improving and reforming the system, not scrapping it, and by focusing our help on the most vulnerable in society—children and seniors."

To whittle down the ranks of the uninsured, McCain would have:

• Increased funding for states' efforts to enroll children in Medicaid and the Children's Health Insurance Program.

• Made it easier for small businesses to form purchasing pools to buy health insurance.

• Expanded the medical savings account program.

• Offered new tax incentives that both encourage employers to provide insurance to employees and motivate individuals to purchase coverage.

• Tried to reform the tort system, streamline the work of the Food and Drug Administration, and make other changes to improve the cost-effectiveness and efficiency of the health care system.

The main criticism of McCain's plan was that it was woefully inadequate. Some of his proposals, such as FDA reform, only obliquely addressed the problem of the uninsured. Others, such as expanding medical savings accounts, seem to be a waste of time; the MSA program has yet to generate enthusiasm among Americans.

McCain was his most vocal on the issue of patients' rights. The ongoing debate in Congress is "about preserving the positions of competing special interests," he said. "It's about the interests of trial lawyers vs the interests of insurance companies—not the interests of patients."

McCain was in favor of patient protection legislation that would put physicians in charge of medical decisions, allow direct access to obstetrician-gynecologists and pediatricians, guarantee coverage for emergency room care, provide continuity of care for pregnant and terminally ill individuals, let physicians speak freely to patients about treatment options, and enable patients to contest managed care organizations' decisions through internal and external appeals processes and in court.

McCain also hoped to provide block grants to states so they can help poor seniors pay for prescription drugs. He wanted to test a state-administered program that helps Medicare beneficiaries with catastrophic illness buy drugs. And he wanted to improve health care for veterans.

The decisive factor

So will Bush and Gore adopt any of those ideas as their own? The public says it wants to hear about health care reform, and in contrast to many other issues, the two major candidates know they must continue to address the topic.

But the question nags: So what?

Do voters really base their decision on a candidate's health care stand, even when the issue hits close to home? In January, before Gore and Bush had captured their parties' nominations, voters surveyed by Kaiser ranked Bush (28 percent) as the best candidate to deal with health care issues. Gore placed second (21 percent), followed by Bradley at the time (12 percent) and McCain (7 percent). "[That] early in the campaign, voters' feelings about which candidates would best handle health care issues seem to reflect the candidates' general standing in the polls," according to the foundation. In other words, personal popularity—rather than policy—drives public opinion.

In addition, almost half of the voters told Kaiser that leadership, character, and moral values will determine their presidential selection. Only 36 percent said that issue-based opinions will guide their voting. Health care issues will be important, concludes Kaiser's Drew Altman. "But they will not decide the 2000 election."

Why Congress won't pass health care legislation in 2000

As a rule, Congress doesn't legislate during a presidential election year. And the rule will most likely hold in 2000.

At the end of last year, Congress left the patient protection act dangling. The House had passed a tough bill that applies to all Americans with private health insurance (about 161 million people) and gives patients the right to sue managed care organizations in state courts. The Senate had passed a bill that applies only to Americans in self-insured health plans (about 48 million people) and has no provision for lawsuits.

Now Congress is in the process of reconciling the two bills. Sen. Don Nickles, R-OK, who chairs the reconciliation committee, says he wants the differences settled and legislation acted upon this month. While patient protection has strong public support, it's doubtful that Congress will enact a bill. More likely, the opponents of patient protection—mostly Republicans—will find a way to stall action without openly voting down the bill.

The reduction of medical errors, a concern that's grown substantially since the Institute of Medicine issued a damning report on the subject late last year, will get a lot of attention. Hearings have already been held, and legislation to require that medical mistakes be reported to state or federal government agencies is under consideration. Congress is unlikely to act on this relatively new issue just yet, but in late February President Clinton said he would order hospitals to institute programs to improve patient safety.

The concept of using tax credits to help poor people buy health insurance has gained popularity with both Democrats and Republicans. President Clinton, Sen. John Breaux, D-LA, House Majority Leader Dick Armey, R-TX, and Sen. Bill Frist, R-TN, are among the leading proponents. But bipartisan support of a concept doesn't guarantee passage of legislation. Odds are that a tax-credit bill will get put off until next year.

At best, Medicare reform will get a polite nod from Congress in 2000. But the idea that seniors should have a prescription drug benefit is gaining momentum. It's a stretch, but Congress could extend limited drug coverage to seniors later this year. Wouldn't that be a nice gift to a large bloc of voters just before the election?

Other issues that may get some attention include physicians' right to bargain collectively, and the financial burdens placed on health care providers by the Balanced Budget Act of 1997.

The top item on the national political agenda is the election, of course. Each party will be cautious during the next few months, for fear it will give the other a legislative victory and bragging rights come November.

If nothing gets done this year, chances are that a backlog of health care bills will demand Congress' attention in 2001. And if the Democrats prevail in November, chances are that those bills—particularly the ones regarding the uninsured—will get a favorable hearing.

Michael Pretzer. Will health care decide who goes to the White House?.

Medical Economics

2000;7:263.