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GOVERNMENT & MEDICINE
Gore, Bush give stances on medicine
The presidential candidates offer clear choices on issues affecting health care.
The stark differences between the presidential candidates on health care issues mean the outcome of the upcoming election likely will have a profound impact on the practice of medicine.
Reforming Medicare and adding an outpatient prescription drug benefit, providing health insurance for more of the nation's 42 million uninsured citizens and protecting the rights of patients enrolled in managed care plans are being debated furiously by Republican candidate Texas Gov. George W. Bush and Democratic candidate Vice President Al Gore.
In general, Bush looks to the private marketplace for help while Gore would tap into existing public programs. On Nov. 7, voters will determine which approach will go forward next year.
Charting Medicare's course
The future path of Medicare, which faces rocky financial times with the impending influx of the baby boom generation, is a key health issue in this presidential election. The philosophical differences between the two candidates are evident in both their overall Medicare reform proposals and their plans to add a prescription drug benefit to the program.
The role the federal government should play in Medicare's administration is one of the biggest differences between the Gore and Bush plans, health analysts said. The vice president's plan leans toward maintaining the government's involvement in Medicare, while the Texas governor's proposal favors reliance on the private sector.
"It really does boil down to how well you believe the private sector can serve the interests of all Medicare beneficiaries, including those who are particularly sick," said Michael Gluck, PhD, scholar in residence at the National Academy of Social Insurance and an associate research professor at Georgetown University, Washington, D.C.
Another key difference between the plans is how they share the risk of seniors' expensive illnesses. Medicare now puts the country's seniors -- poor or wealthy, sick or healthy -- into one large insurance pool that spreads risk among everyone, Dr. Gluck said. Gore's plan largely preserves that risk-sharing system, while Bush's proposal segments it by allowing seniors to choose among locally run health plans.
Comprehensive reforms in the Gore plan include taking Medicare off budget and putting trust fund surpluses into a lockbox, which he says would bar lawmakers from using the money for tax cuts or spending increases.
Under Bush's reform plan, private insurers would offer different Medicare benefits packages, which would cover prescription drugs and other expanded benefits. Seniors could select one of these expanded benefits plans or choose to remain with only the existing Medicare benefits package. He also would create a bipartisan Medicare commission charged with putting a formal comprehensive reform proposal in legislative form after it considered his plan and other suggested fixes.
In Bush's proposal, the premiums, deductibles and co-payments beneficiaries would pay would vary depending on the expanded benefits plan they chose. All individuals with annual incomes above $14,600 would receive a 25% subsidy to help pay the premium for their prescription drug coverage. Medicare also would pay for seniors' health bills once their out-of-pocket expenses for all benefits exceeded $6,000 annually.
Bush estimates that his Medicare reform plan, including the prescription drug component, would cost $110 billion over 10 years. Part of his plan also calls for an additional $48 billion to be given to states so they could create or expand their own drug assistance programs for Medicare beneficiaries.
Gore's Medicare prescription drug plan, essentially the same one offered by President Clinton, is estimated to cost $253 billion over 10 years. The drug benefit would be added to the existing Medicare program and would be managed by pharmacy benefit managers.
Seniors would pay a $25-per-month premium for the drug benefit in 2002. The plan has no deductible. The government would cover half the cost of prescription drugs up to $5,000 and provide catastrophic protection once a senior paid $4,000 in out-of-pocket expenses.
The two candidates' drug plans do share some similarities, analysts said. Both offer some sort of subsidy to low-income seniors that would help them pay for the Medicare drug benefit, said Jeff Lemieux, senior economist at the Progressive Policy Institute.
Dr. Gluck also noted that both candidates recognize that seniors would have to shoulder more of the cost of a drug benefit than they do for other benefits Medicare now offers.
Coverage for uninsured
Both Gore and Bush have won friends among those who believe the nation's uninsured citizens should have greater access to affordable health insurance.
"We are pleased that both candidates are addressing the health care issues and particularly the issue of the uninsured," said AMA Board Chair D. Ted Lewers, MD.
But each candidate would pursue a very different path to gain that additional coverage.
Bush looks to the private sector to provide the answer by proposing an annual refundable tax credit of $1,000 for an individual and $2,000 for a family to use when purchasing health insurance. The credit would vary depending on income and be available only to those whose employers do not offer health insurance.
Many Bush opponents were quick to point out that the proposed subsidy would not likely be sufficient to enable low-income families to purchase policies that now average about $6,000 per year. But implicit in the Bush plan is the belief that insurance companies will respond to this market and develop more basic, low-price policies that would be affordable, said Robert Blendon, ScD, Harvard University professor of health policy and politics. "The question will be: What will people sell in the marketplace?"
In sharp contrast to Bush's insurance reform proposal, Gore would focus on the expansion of public programs to provide additional health insurance coverage to low-income people.
Gore has placed a special emphasis on expanding coverage for children and has promised that, under his administration, all children will have access to affordable health care by 2005.
He proposes expanding the State Children's Health Insurance Program to cover children in families with incomes as high as 250% of the federal poverty level. Currently only those with incomes up to 200% of poverty are eligible.
Gore also would allow families that earn more than 250% of poverty and that do not already have health insurance to buy SCHIP or Medicaid coverage for their children. Gore said he also would provide states with financial incentives to enroll children in the programs.
To cover more adults, Gore proposes opening SCHIP enrollment to parents of eligible children and allowing people between 55 and 65 to enroll in Medicare.
Bush takes a different approach to the SCHIP program. He would ease regulations and transform the 3-year-old state and federal effort into a state block grant program.
In another clear difference between the candidates, Bush would make medical savings accounts, which are set to expire at the end of this year, a permanent option and expand their availability.
Gore opposes medical savings accounts, which allow people to set aside money tax-free for medical expenses. He argues that they would remove younger and healthier people from the insurance risk pool and drive up premiums for those who remain.
In additional health policy proposals, Bush would allow small businesses to purchase health plans from multistate trade associations to give them access to the same benefit that economies of scale afford large businesses. He also would exempt association-sponsored health plans from certain state mandates to allow development of more low-cost products.
Gore would provide small businesses a 25% refundable tax credit to be applied toward the premium cost of health insurance for employees. He would provide a similar tax credit to individuals buying insurance on their own.
When looking at the numbers of uninsured people covered under the candidates' proposals, Gore's plan would cover about 6 million to 8 million people, and Bush's plan would cover about 2 million to 4 million people, said Len Nichols, a health economist at the Urban Institute in Washington, D.C.
"So neither of them is going to solve the problem of the uninsured," Nichols said.
Differences between the candidates on how best to protect patients' rights under managed care are more difficult to tease out than their other health care policy differences.
Texas has been a leader in patients' rights. That state passed a law in 1997 that provides many of the rights included in a national bill favored by the AMA and passed by the U.S. House of Representatives. As governor, Bush allowed the Texas bill to become law without his signature.
"As president, Gov. Bush will enact comprehensive patient protections similar to those already enacted in Texas," his spokesman, Dan Bartlett, has said. Among the protections provided in Texas is patients' right to sue their health plans if they are hurt because the plan denied or delayed necessary treatment.
Bush has not endorsed either the House bill or a much less extensive Senate-passed patients' rights bill. He has said that any federal patient protection legislation must not undermine reforms already enacted by states.
Gore is a major supporter of the House-passed bill, which includes an expanded right to sue health plans and covers all 160 million people enrolled in group health plans. Its Senate-passed counterpart would cover 60 million people in most cases and does not include an expanded liability provision.
"If you look at the two camps, both want to rein in some of the excesses of managed care, but they differ a bit around the edges," said Randall Bovbjerg, a principal research associate with the Urban Institute.
The differences are most pronounced in their views of states' rights vs. national uniformity, Bovbjerg said. While Bush favors the right of states to enact their own laws, Gore supports the House bill and the strong national uniformity it would bring, he said.
Larry Levitt, director of the Kaiser Family Foundation's Changing Healthcare Marketplace Project, agreed. "Basically, Bush is supportive of patients' rights, but seems uncomfortable with preempting states' rights," he said.
Medicare: "I'll fight for a prescription drug benefit for all seniors under Medicare. It's just wrong for seniors to have to choose between food and medicine, or between one crucial medicine and another, while the big drug companies run up record profits."
Uninsured: "Although we have made tremendous economic progress over the past seven years, too many Americans still lack affordable health insurance. I believe we can change that. Part of my health care proposal is to provide a refundable tax credit to individuals who purchase their own health insurance ... and a similar tax credit to small businesses."
Patients' bill of rights: "There is something wrong with our system of health care when life-or-death decisions are made not by a doctor or a nurse, but by an insurance company accountant sitting at a computer screen hundreds of miles away."
Medicare: "We will give all seniors a number of additional options, so they can choose a better policy that meets their individual needs, including benefits like preventive care, vision care and dental care. ... All [plans] must offer the minimum Medicare benefits and can add additional services to compete for customers."
Uninsured: "We will not nationalize our health care system. We will promote individual choice. We will rely on private insurance. But make no mistake: In my administration, low-income Americans will have access to high-quality health care."
Patients' bill of rights: "During my tenure in office, Texas enacted one of the most comprehensive patient protection laws in the nation. I would support similar protections at the federal level provided they do not supersede the patient protection laws."
The Bush-Cheney campaign (http://www.georgewbush.com)
The Gore-Lieberman campaign (http://www.algore2000.com)
Box: The candidates