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
HIGHLIGHT:
Democrats think they've found an
issue that will put Republicans
on the defensive in the races for the White
House and Congress.
BODY:
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
resistance.)
"Democrats have tried to do the
people's business. We
tirelessly worked to get our top priority-a
patients' bill of
rights, 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
issue.
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
Hampshire.
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
supporter.
"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
confused."
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
time."
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
place."
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."
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