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Washington Perspective

With health care issues, the presidential candidates' differences emerge

From the October 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Some presidential elections become a battle between candidates with compellingly different philosophies of government. What is remarkable about the 2000 election is that at least on the surface, there doesn't appear to be much of a philosophical divide between Vice President Al Gore and Texas Gov. George W. Bush.

Both candidates are campaigning on a moderate agenda designed to appeal to "centrist" swing voters, not the ideologues in their own parties.

Mr. Gore has campaigned as a populist, using the slogan "fighting for the people against the powerful." But his campaign proposals notably lack any Great Society-type income redistribution programs favored by true liberal populists.

Mr. Bush has campaigned as a "compassionate conservative," and his philosophy accepts big government's role as a catalyst for change. In proposing his Medicare prescription drug plan, he even lauded Medicare as a success of the Great Society era of activist government.

The candidates' specific policy prescriptions, however, show strong differences. Although both use moderate language, the specifics of their proposals reveal their divergent views of the role of government. Simply put, Mr. Bush views the government as a source of funding for changes that should be carried out by the private sector and state and local governments. Mr. Gore, on the other hand, puts his trust in the federal government to bring about change.

Medicare drug benefit

This difference can be seen most clearly in each candidate's approach to Medicare. Both candidates favor a prescription drug benefit for Medicare beneficiaries. But Mr. Gore would do so by giving beneficiaries the option to purchase drug coverage through the Medicare program itself, with the federal government heavily subsidizing the premium.

Mr. Bush, by contrast, has proposed a two-step program that would begin by giving grants to state governments to provide drug coverage to needy citizens. Later, a federal subsidy program would help beneficiaries buy coverage through private health insurance plans.

Most significantly, the Bush proposal envisions giving beneficiaries the option to buy all their Medicare coverage through the private sector, including—but not limited to—prescription drugs. Beneficiaries would also have the option to remain in traditional Medicare, with or without supplemental drug benefits.

The Bush plan represents a major overhaul of Medicare, not just an expansion of the existing program to include prescription drugs. It converts Medicare from a pure defined-benefit program (in which the federal government directly guarantees the benefits) to a defined contribution program. Private sector plans would have a great deal of flexibility in deciding how to provide the required benefits, including what copayments and deductibles might apply.

Although beneficiaries can currently join private sector Medicare+Choice plans, the Bush plan would give them a check to purchase coverage directly from private companies. If patients bought a plan that cost less than the government's contribution, they could pocket the difference. If they chose a plan that cost more, on the other hand, they would have to pay the difference.

The Gore plan, by contrast, would subsidize the voluntary purchase of supplemental prescription drug benefits through Medicare itself. The federal government would determine copayments, deductibles and other benefit rules. Mr. Gore would also put any government surpluses generated by Medicare directly into a "lock box" to shore up the future solvency of the program.

Expanding insurance coverage

Both candidates have said that all Americans should have health coverage, but neither has put forth a plan that would achieve this goal.

Mr. Gore would expand coverage to all children and the working poor by expanding existing federal programs such as Medicaid, Medicare and the Children's Health Insurance Program (CHIP). He would expand CHIP to include more low- and moderate-income children and their families, and he would hold states accountable for signing up eligible children. Americans agedX 55 to 65 would be given a tax credit to buy into Medicare. Small businesses would receive a tax credit to provide health insurance coverage to their employees.

Mr. Bush, on the other hand, would offer a $2,000 tax credit to families that don't qualify for Medicaid and that aren't covered by an employer plan to help them purchase private insurance. Small businesses could buy affordable coverage at group discount rates through multistate associations, and the plans would be exempt from their state's rules regulating benefits. States would also be given more flexibility in how they provide coverage under the CHIP program, and incentives would encourage individuals to buy high-deductible medical savings accounts.

Finally, Mr. Bush favors large, across-the-board income tax cuts, while Mr. Gore advocates for a more limited package of targeted tax breaks for education, long-term care, home ownership and other priorities. Mr. Gore's strategy has allowed him to put more money into his health care proposals than Mr. Bush. Mr. Gore argues that his plans will help more Americans get health care coverage than Mr. Bush's; Mr. Bush counters that his proposals would help everyone directly by giving them "back" their own tax-paid surplus dollars.

Choices for internists

When internists cast their votes in November, they will have to weigh which governing philosophy is more likely to help them and their patients. One candidate builds upon the successes of current government entitlement programs by expanding coverage and eligibility; the other looks to the private sector and state governments to provide the necessary coverage, with financial help from the federal government for those who need it.

As a nonpartisan organization, ACP-ASIM will not endorse either candidate. From our standpoint, though, it is good news that health care issues have become so prominent in both presidential candidates' agendas.

This suggests that next year, we may see real progress toward expanding health insurance coverage, making prescription drugs affordable and addressing other concerns of internists—regardless of which candidate prevails on election day.

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

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