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Copyright 2000 The National Journal, Inc.  
The National Journal

January 8, 2000

SECTION: HEALTH; Pg. 86; Vol. 32, No. 2

LENGTH: 4332 words

HEADLINE: Campaign Medicine

BYLINE: Marilyn Werber Serafini


Democrats think they've found an issue that will put Republicans
on the defensive in the races for the White House and Congress.


Nashua, N.H.-Vice President Al Gore listens intently as Florence
Seitz, a sweet-voiced elderly woman, mesmerizes a roomful of New
Hampshirites with tales of prescription drug woes. Describing
what it's like to live on a monthly fixed income of $ 658, Seitz
relates how she places her six pill bottles on her kitchen table
every month, then decides which ones she can afford to refill,
which pills she will have to take every other day, and which ones
she'll have to do without.

     Gore nods the understanding nod of a Democrat who is
promising to help people like Seitz. Campaigning at the Southern
New Hampshire Medical Center, he encourages her to fill in the
painful details. Her story provokes anger from the audience-and
from Gore-about drug company profits and the shortcomings of
Medicare. It also creates an effective introduction to many of
the campaign promises he is about to make.

     "My goal is to have universal health insurance for every
American," he says, pausing for applause. Then he describes how
he would extend Medicare's solvency by spending 15 percent of the
budget surplus over the next 15 years on the health insurance
program, add a prescription drug benefit to Medicare to help
people like Seitz, enact a bill of rights for patients in HMOs
and other managed care programs, and give relief to people who
provide long-term care to friends and family.      Gore has made health care reform a central part of his
campaign for the Democratic presidential nomination. So has his
main competitor, former Sen. Bill Bradley of New Jersey. Both
candidates have unveiled detailed health care proposals that
address everything from the uninsured (now one in six Americans)
to patients' rights. And although their proposals are very
different, the campaign message is the same: Democrats, not
Republicans, are the ones who will do something about the issues
that families care most about. The Republican talk about tax
relief, they maintain, simply shows that the party is out of
touch with the public's priorities.

     Congressional Democrats, as they attempt to regain
control of the House and Senate, are riding the same theme by
emphasizing their commitment to a patients' bill of rights and a
Medicare prescription drug benefit. (Congress failed to pass
bills on either subject this year, and Democrats blame Republican

     "Democrats have tried to do the people's business. We
tirelessly worked to get our top priority-a patients' bill of
on the floor of the House," House Minority Leader Richard
A. Gephardt, D-Mo., said in November. "And now, the
pharmaceutical industry and their allies in the Republican
leadership are committed to making sure (that Medicare
prescription drug) legislation never sees the light of day."

     Republicans, however, aren't ignoring health care. A
handful of congressional Republicans proposed bills last year
that would decrease the number of uninsured by giving them a tax
credit to buy insurance on their own. Moreover, the Republican-
controlled Senate passed a patients' bill of rights. And in the
House, nearly 70 Republicans voted for the Democratic-sponsored
patients' bill of rights that passed that chamber.

     But in the presidential race, Republican candidates don't
talk about health care much unless they're asked about the
subject. Texas Gov. George W. Bush has said he could support
giving patients the right to sue their health plans, if the
measure is similar to one in place in Texas. Bush did not sign
the Texas bill, but he allowed it to become law. His advisers
have been considering a plan to make insurance more available,
but he hasn't offered an actual proposal. Bush's main competitor
for the GOP nomination, Sen. John McCain, R-Ariz., has talked
more than Bush has about health care, but he has not offered a
plan as comprehensive as Bradley's or Gore's.

     Health care is historically a tough issue for
Republicans. Attempts by congressional Republicans in 1995 to cut
the growth of Medicare spending gave Democrats ammunition in the
1996 election, which saw Democrats regain some House seats they
had lost in 1994 and President Clinton easily win a second term.

     Health care is an easier issue for Democrats to talk
about, agreed Republican pollster William D. McInturff, a partner
in Public Opinion Strategies. "It's very probable that the issue
of the uninsured, health care costs in general, and the
continuing debate about prescription drugs and Medicare are all
going to be a part of the 2000 election," McInturff said. "And,
as always, because of the cost of these programs, the Democrats
will be much more aggressive on these issues because of where
they would be willing to talk about putting money. It leaves
Republicans a little bit on the defense, because we don't have an
answer of a funding source."

     Steve Duprey, who heads the Republican Party in New
Hampshire, said that Republicans will address health care as the
2000 campaign develops. For now, Duprey said, candidates are
concentrating on other important issues, such as the size and
scope of government, education, and foreign affairs.

     As for Democratic claims that the GOP is out of touch
with the will of the people, Duprey scoffs. "It's typical for
Democrats and how they campaign to try and demagogue issues," he
said. "Education is another example. Democrats claim to be the
only ones good for education. Here in New Hampshire, the
Democratic Party comes through town, promises all kinds of
programs, but they don't deliver. Our approach is going to be 'Do
you believe the Democrats, who tell you they will give you five
new programs, then they don't fund them after the campaign?' "
Who Cares About Health Care?
It's no wonder that Democrats are spotlighting health care, and
that Republicans are seeking inoculation against Democratic
attacks. Recent polls show that, as the 2000 election approaches,
people are more worried about health care than almost any other

     In a Washington Post poll conducted in October,
Republicans, Democrats, and independents alike said that concerns
about HMOs were their top worry. Democratic respondents also
cited concerns about elderly people being unable to afford
medicine and about their own fear of losing medical benefits.
Independents said that school violence was their second-greatest
concern, and the affordability of medicines for the elderly was
their third-biggest worry.

     Similarly, a poll conducted in October by Peter D. Hart
and Robert M. Teeter for NBC and The Wall Street Journal listed a
number of bills that Congress debated in 1999 but failed to
enact, and it asked respondents which one they cared about most.
The top disappointment was Congress's failure to pass a patients'
bill of rights.

     "These are real personal issues," said Ron Pollack, the
executive director of FamiliesUSA, a family-advocacy group in
Washington. "Nine out of 10 people may not know where Kosovo is,
but they know where their doctor is, and they know what their
family needs in terms of health care. When you deal with an issue
that is, in and of itself, important, it makes for something that
is very compelling."

     It's unusual for health care to rank so high in pre-
election polls, said Greg Stevens, a Republican media consultant
for Stevens Reed Curcio and Co. in Alexandria, Va. "I've been
doing this business for 25 years, and I don't recall a time when
(health care) was more important going into an election."

     Tom King, a Democratic media consultant for Fenn and King
Communications in Washington, said that insecurity is driving the
numbers. "It's resonating out there. People have a fear of what's
going to happen. They feel their HMO can knock them off."

     Even though the ranks of the uninsured are declining in
New Hampshire, local health care activists say that people are
worried. "In New Hampshire, people are really experiencing a
sense of insecurity, whether you're uninsured or whether you're
insured," said Ann Widger Crowley, the lead organizer for New
Hampshire Asks, an advocacy group that presses candidates to talk
about health care reform.

     In New Hampshire, as in most of the other states, health
insurance premiums are on the rise. And health plans that serve
both Medicare and the under-65 population have been leaving the
state. "So you've got the insured and the uninsured almost in the
same boat of insecurity. And that is really raising the issue of
health care in this state, in particular," said Crowley.

     Health care activists for such groups as the AFL-CIO,
Citizens for Long Term Care, and Consumers Alliance say they're
pleased with all of the attention their issues are getting from
Gore and Bradley, and they vow to keep pushing Republicans. "It's
great that they (Gore and Bradley) are talking about covering
more people," Crowley said. "Each one has pluses and minuses, but
at least they're talking about it, and we're not seeing it from
other candidates."

     Indeed, the two Democratic contenders have focused so
heavily on health care, and spent so much time criticizing each
other's plans, that they've created some uneasiness and confusion
among party supporters and health care activists. "Both
candidates needed to find areas of differences between the two of
them, to distinguish themselves from one another, and this
happens to be one area where they have differences in approach,"
said Kathleen N. Sullivan, who heads the Democratic Party in New

     This hasn't caused a problem-yet, said Sullivan. In a
two-person race, she said, she's not surprised to see that
they're fighting hard. Sullivan said she'll be concerned only if
the bickering "turns people off from the process. You don't want
people to say, 'Oh, there they go, there they go, acting like
typical politicians,' and that's a danger. It's one thing to talk
about issues, and differentiate yourselves on issues, but if it's
seen as being negative or dirty, then that does set a lot of
people off, unfortunately," she said, especially at a time when
Democrats are trying to attract independent voters.

     Gore vs. Bradley
In September, Bradley became the first presidential candidate to
unveil a major health care proposal. The plan won praise from
such health care leaders as Rep. Fortney H. "Pete" Stark, D-
Calif., who has long advocated a national health care system that
would cover all Americans.

     But it also drew criticisms from health care activists
who historically have supported comprehensive reforms. "Bradley
deserves credit for raising the issue in such a broad way," said
FamiliesUSA's Pollack. However, he added, "I don't think the
proposal he's got really hits the mark. . . . I think that his
plan is not very well thought out."

     Bradley's proposal would require parents to get health
care coverage for their children; shift Medicaid enrollees into
private health insurance; and allow anyone to buy into the
Federal Employees Health Benefit Program, which now covers
federal workers, including members of Congress. People below the
poverty level and low-income earners would get subsidies on a
sliding scale. Bradley's program would be open to anyone, even
those people who now buy health insurance through an employer or
on their own.

     Bradley contends that Medicaid has not effectively helped
the poor. Many of the people who are eligible don't sign up, he
notes, and enrollment of children is actually declining.
Moreover, he says that 70 percent of doctors won't take Medicaid
patients because the reimbursements from the states are too low.
Bradley also would add a prescription drug benefit to Medicare
with a $ 500 annual deductible, $ 25 monthly premiums, and a 25
percent co-payment.

     Gore quickly and sharply criticized Bradley's proposals.
"Sen. Bradley's plan falls short of what I think the American
people deserve," Gore said in his Dec. 14 New Hampshire remarks.
"But he's a good man. He's a good man with a bad plan."

     Gore complained that Bradley's plan would eliminate
Medicaid and the Children's Health Insurance Program (CHIP)-two
programs that Gore says have been effective in covering the poor
and near-poor. "Eliminating Medicaid is fine, if we can replace
it with something better," he said. "But capping premiums at $ 15
per month makes it impossible to acquire benefits anywhere near
approximating those available under Medicaid."

     He also complained that Bradley's Medicare drug proposal
would require seniors to spend $ 800 a year out-of-pocket before
seeing any benefit. "The average senior has $ 413 per year in
prescription drug costs. More than half of seniors on Medicare
have expenditures less than $ 500. They would pay the $ 800 a year
and get nothing in return. I think that's a mistake."

     But the biggest flaw in Bradley's plan, Gore says, is
that it would use up the budget surplus but result in the same
number of uninsured as Gore's less costly plan. How is that
possible? Gore argues that two-thirds of Bradley's $ 65 billion-a-
year program would go to cover people who already have insurance.

     Gore quickly followed up Bradley's proposal with a plan
of his own that takes a more-incremental approach. Gore proposes
to build on the existing health care system, first by getting
more children into CHIP and Medicaid. He also would give the
parents of children in Medicaid and CHIP access to those
programs. In addition, uninsured people between 55 and 65 could
pay for Medicare coverage. For other uninsured people, he would
offer a 25 percent tax credit to help them buy coverage on their
own. Gore also has a prescription benefit plan for Medicare that
has no deductible, a 50 percent co-insurance, and a maximum
benefit of $ 2,000 a year at first, increasing to $ 5,000 in 2008.
Gore estimates that his plan would cover 88 percent of the
population with some sort of health care. About 83.7 percent of
Americans now have coverage Bradley disagrees. "The Gore proposal
relies on expanding a complex patchwork of programs that have not
yet succeeded at their original missions," he said in a
statement. He added that the early buy-in for Medicare would be
so expensive that it would bring in only about 300,000 people.
"Vice President Gore must know that his symbolic proposal,
despite its complex array of new eligibility categories, would
not meaningfully expand health care coverage for children or for
needy adults," Bradley said.

     The spirited exchanges have split health care activists,
and that hurts Democratic efforts, according to Steve Gorin, the
co-chairman of New Hampshire Asks and a professor of health care
policy at Plymouth State College. Personally, he's a Gore

     "I'm very disappointed at Bradley's approach," he said.
"I don't think it's a serious contribution to the debate over
health care. It was calculated as a way of dividing health care
activists and pulling people over to Sen. Bradley. . . . The
perception is that Gore is attacking Bradley for spending money
and having big ideas. I think he's attacking Bradley for having
bad ideas and spending money foolishly. Many activists are

     Some health care analysts say they were surprised that
Bradley produced a plan that would so radically change the health
care system after the Clinton administration's comprehensive
reform effort failed in 1994 and contributed to the Democrats'
loss of majority control of Congress in the subsequent election.
Many health care activists have sided with Gore because they see
his proposal as more achievable.

     "A lot of the people who do this health care stuff for a
living are deathly afraid that we will do away with Medicaid,"
said one health care analyst. "No matter how well-intentioned, it
sounds like a Republican idea." But in eliminating known
programs, people are uneasy about what will replace them, he
said. "Better the devil you know than the devil you can't figure
out," he said.

     Moreover, the analyst said, health care activists are
siding with Gore because they've grown to trust him since the
Clinton health care plan failed in 1994. "By and large, the
activists found friends in the Clinton administration, and in
Gore-whether (it was) AIDS policy or research or CHIP, Medicare,
or Medicaid flexibility. They looked for help to the White House,
and they got it."
Hammering on the Hill
While Gore and Bradley club each other's proposals, Democrats are
promising to keep the health care hammer swinging at Republicans
on Capitol Hill. Consider a Nov. 9 rally at the Capitol.

     About two dozen House Democrats squeezed into a crowded
Capitol Hill hearing room alongside first lady Hillary Rodham
Clinton to try to boost a bill that would add a prescription drug
benefit to Medicare. But there was clearly something more in
Democrats' voices than the desire to create a new Medicare
benefit. Nearly every speaker-from the first lady to Gephardt-
claimed that the Republicans don't care about health care and
therefore don't care about families. Then, with little pause,
they predicted Democratic wins on Election Day. "The Democratic
Party is the only party that is fighting for the issues that
people care about," said Clinton. "Republicans in Congress just
don't get it."

     Perhaps the Democrats' biggest complaint is that GOP
leaders resisted passing a patients' bill of rights. Senate
Republicans ushered through a bill that Democrats criticized as
weak, and Democrats had to force a bill through the House that
GOP leaders opposed, but about 70 Republicans supported.

     "The House leadership clearly came down on the side of
the health insurance industry," said Erik Smith, the
communications director for the Democratic Congressional Campaign
Committee. "This is a story we will tell. The question will be:
'Do you want your health care decisions being made by faceless
insurance company bureaucrats, or do you want the decision made
in counsel with your family doctor?' "

     Congress also did not pass a Medicare prescription drug
bill this year. It's hard for Republicans to address Medicare for
one basic reason, according to health care analysts and
pollsters. "Medicare is perceived to be a health care issue that
actually does take some money to solve," said Celinda Lake, a
Democratic pollster. A prescription drug benefit for Medicare
could cost up to $ 20 billion or $ 30 billion a year.

     "I think the Democrats feel the patients' bill of rights
is something they can't lose on," said Pollack. "On Medicare, I
think again the Democrats feel that Medicare is an issue that's
always been very helpful to them . . . I have no doubt that these
are going to be the issues the Democrats are going to push."

     But Rep. Greg Ganske, R-Iowa, a physician who worked with
Democrats to pass a patients' bill of rights in the House,
predicts that Republicans could rebound politically if they play
their cards right. "If we change course, and a good strong bill
comes out of conference, something the president can sign, then,
low and behold, we have a big accomplishment to put in our
election basket." Republicans can learn a lesson from President
Clinton's role in welfare reform, Ganske said. "He fights it,
fights it, fights it, and finally decides he has to sign it, so
he goes out and takes credit for it."

     Democrats, however, remain unconvinced. "Republicans are
setting themselves up for hard knocks over this issue," predicted
Rep. John D. Dingell of Michigan, the ranking Democrat on the
House Commerce Committee. "Not only have they opposed the
legislation, but they did everything they could do to avoid a
fair vote. They added a series of procedural hurdles and
difficulties to passage. We had to have four successive votes
before we could get a vote on our proposal. I anticipate this is
a very legitimate issue that will be raised on our side. I'll be
interested to see how active Republicans will be. I suspect
they'll be mightily silent.

     "This is really resonating with voters," added Dingell.
"Those who don't listen to the voters will have a difficult time.
This is resonating with voters like nothing I've seen in a long

     The patients' bill of rights will almost certainly help
Democrats politically, said one Democratic congressional aide,
who offered two possible scenarios. First, the aide said, a
"good" bill could emerge from conference committee this year and
get signed into law. Second, no bill or a bad bill could emerge
from conference. "Either way, the subject becomes part of the
more intensified political reality (in 2000). Either result isn't
bad. If there's a bill, it's a substantive accomplishment. If
there's no bill, people who opposed it are going to have to
justify their position in the election."
GOP Defense
For now, many Republicans are content to sidestep Democratic
attacks on health care, said GOP media consultant Greg Stevens,
by talking about other issues where Republicans have an advantage
and addressing health care when asked about it. But Stevens is
cautioning candidates not to "hide and duck under the desks."
Those candidates, he said, will "potentially pay at the polling

     Opponents of some of the Democratic health reform
initiatives say that Republicans can make a case that will
resonate with voters. "Because of a number of mandates (on health
plans) already passed around the country, costs are inching up
around the country. There's a solid connection," said Karen
Ignagni, the president of the American Association of Health
Plans, which represents most HMOs. "If you add liability to that,
you add another 3-to-8 percent to that. That is very, very
significant at a time when health care costs already are inching
up to double digits. In labor negotiations, employers are talking
about dropping health care coverage because they can't offer
insurance. It's an Achilles' heel here for working families who
may not have had an opportunity to assess who will pay, and how
they will be affected."

     And there's no question that Congress's failure to pass
Medicare legislation this year was not Republicans' fault, GOP
supporters say. Many Republicans wanted to pass a proposal put
forward by Rep. Bill Thomas, R-Calif., and Sen. John Breaux, D-
La. The two chaired a Medicare commission, and they proposed
sweeping changes to the program along with a modest prescription
drug benefit. The proposal was not presented as a formal
recommendation because not enough Democratic appointees on the
committee voted for it.

     Republicans also can be credited with pushing through a
relief bill for medical providers who were hit hardest by
reimbursement cutbacks in the Balanced Budget Act of 1997.

     Still, it's apparent that Republicans have yet to unite
behind a strategy for dealing with health care as an election-
year issue. Ganske notes that the House GOP leadership, in
packets of information advising members on how to address
particular subjects in their districts, has remained silent on a
patents' bill of rights.

     Stevens says he'll advise Republican clients to step up
to the plate. "It really is important for us to have something to
say other than that we support the insurance companies and HMOs.
This has to be handled very carefully. We have to show great
concern for the consumer and the patient. We have to find ways to
send messages to the voters that we care about them as much as we
care about the insurance companies."

     If Republicans can counter the Democrats' attacks on
health care, said Stevens, they can win politically. "If they can
neutralize the issue, if they can say something that they care
and work on reasonable commonsense approach to the issue, they
can get onto issues that they can win on."

     Republicans must address health care issues, because
they're being asked about them on the campaign trail, said
McInturff, who does polling work for McCain. "When John comes
back from campaigning around the country, he says, 'Hey, let's
talk about health care.' Because everywhere he goes that's what
people ask him about. When you ask and debrief a candidate and
ask what people are asking you, they say that real people are
asking about health care, prescription drug benefits, their
irritation with managed care."

     New Hampshire state party Chairman Duprey predicts that
the defining issue in the presidential election will not be
health care, but character. "Call it Clinton fatigue. Clinton
dislike. People want a president they can look up to and their
children can look up to. Clinton disgraced the office."

     Sure, there are health care issues in New Hampshire, and
Duprey may know them as well as anyone. Duprey owns a property
management business that employs 63 people. This year, his health
plan raised premiums by 39 percent. But, he said, at least there
are health plans in the state. "Eight years ago I had a hard time
finding carriers. Now we've got double-digit increases. But at
least we've got coverage."

LOAD-DATE: January 13, 2000

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