The presidential elections: how will health care fare?

From the July/August 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Every four years, presidential elections provide an opportunity to elevate health care issues to the top of the national agenda.

It has been 36 years since Lyndon Johnson's landslide victory paved the way for the enactment of Medicare and Medicaid in 1965. Since then, however, presidents have come and gone, and for the most part, the health care reforms that they initiated have been comparatively modest ones.

Richard Nixon, for example, put the federal government squarely behind the HMO movement and was the first to institute price controls for Medicare. Ronald Reagan instituted policies designed to control the costs of Medicare and Medicaid that included prospective pricing for hospitals and a freeze in payments to physicians.

George Bush's legacy includes the Resource Based Relative Value System, volume performance standards and the Medicare fee physician schedule. Bill Clinton tried to get universal health care coverage enacted, but ended up settling for an incremental expansion of coverage to poor children (the Children's Health Insurance Program) and small insurance market reforms (the Health Insurance Portability and Accountability Act).

What can we expect if Gov. George W. Bush or Vice President Al Gore is elected president? Can we expect the kind of massive changes that President Johnson helped bring about? Or will we see more of the small, incremental changes that have been the hallmark of every presidency since then?

The candidates' promises

Based on what Vice President Gore and Gov. Bush have promised so far, it looks like we can expect "more of the same." Both candidates have talked about expanding access to health insurance coverage, but their ideas so far have been relatively small responses to a very big problem.

The problem, of course, is that more than 44 million Americans are uninsured. The proposals from both candidates would use a combination of tax credits to help low-income individuals purchase coverage and expand existing programs to make coverage available to more Americans. But even under the most optimistic scenarios, millions of Americans would still go without health insurance coverage under either candidate's remedies.

This is not to say that there aren't real differences in the candidates' plans. Vice President Gore's proposal would cost more and would emphasize making coverage available to all children. Gov. Bush's plan would cost less and emphasize making coverage affordable for most low-income Americans through tax credits to buy private insurance. But if the goal is health insurance coverage for everyone--as the College believes it should be--both candidates' plans fall short.

Other health issues on the candidates' agenda tend to focus on unfinished business from the current administration and Congress. Both candidates favor a Medicare prescription drug benefit but disagree on the specifics.

Both have shied away from making big proposals to keep Medicare solvent into the future. Vice President Gore, for example, has proposed sustaining Medicare by dipping into the federal budget surplus and using what he calls a "lock box" to assure that the money goes only toward sustaining Medicare and not other programs.

Gov. Bush, however, has criticized the "lock box" proposal as an accounting gimmick, and he has argued that propping up Medicare through surplus dollars doesn't really solve the problems facing the program. He has yet to offer his own plan for sustaining Medicare, however.

Both candidates say they support a patient bill of rights, although Vice President Gore castigates the Republican Congress for "blocking" a strong patient rights bill. Gov. Bush has refrained from commenting on the current impasse in Congress on patient rights, but he has pointed out that he signed into law a strong patient rights bill in Texas that holds health plans liable for their decisions--the most contentious issue in Congress today.

Although both candidates describe health care as an important issue, it is just one of many issues in the election. The fact is that education, Social Security reform and missile defense receive even more attention from the candidates than health care. It's an implicit acknowledgment of the difficulties in finding a winning approach to health care reform.

Do the elections matter?

Even if the two candidates decide to make health care reform a top priority, they will not likely have a strong mandate from voters. Political pundits expect that the 2000 election will be one of the closest races in history. No Lyndon Johnson or even Ronald Reagan-style landslide is expected.

Nor do the congressional elections point to big changes. The Republicans are expected to continue to control the Senate. The House of Representatives could switch to Democratic control or remain under ostensible Republican control, but by the smallest of margins. Neither the Democrats nor Republicans are likely to have a solid enough congressional majority to move issues forward without cooperation from the other party and the president.

Hearing all of this, cynics might conclude that the 2000 elections really are much ado about nothing. But elections do matter. Even if the candidates aren't willing to go as far as the College and others would like on health care issues, the elections can make a difference.

With issues like universal coverage, ACP-ASIM's Decision 2000 campaign is based on the belief that sustained advocacy throughout the campaign will make the candidates more willing to consider bolder approaches to expanding coverage once they are elected. At the very least, the College's efforts will reduce the likelihood of the candidates simply ignoring the problem, and our efforts put us in a stronger position to influence policies after the election.

Big health care reforms may not be on the candidates' agendas. But the efforts of the College to raise the profile of health care issues will pay dividends in the future by making the candidates more receptive to our concerns, as well as our ideas for solutions.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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