American College of Physicians: Internal Medicine — Doctors for Adults ®


What role will health care play in the 2004 elections?

From the October ACP Observer, copyright 2003 by the American College of Physicians.

By Robert B. Doherty

As the nation heads toward the first wave of caucuses and primaries to nominate a Democratic candidate for president, pollsters are finding that the electorate is in a highly unsettled state.

Several months ago, the conventional wisdom was that the Republicans and President Bush would benefit if the election turns on national security issues. But recent polls suggest that the war in Iraq is polarizing the electorate along party lines: The vast majority of Republicans express continued confidence in the president's handling of the war, while equally large majorities of Democrats now view the war as a mistake.

Continued high rates of joblessness, particularly the loss of manufacturing jobs in key Electoral College "rust-belt" states, are also creating worries for President Bush. Although things could still play out in a way where the president wins re-election by a landslide, many pollsters are now predicting that the race will be a close one, with the electorate being as divided as it was in the 2000 elections.

Voters and health care

Although national security and the economy are trumping all other issues in recent polls, the Democratic candidates are gambling that health care will turn out to be the issue that will tilt the election in their favor. Every one of the 10 Democratic candidates has endorsed the goal of universal coverage. Their proposals range from a Canadian-style single-payer plan to "hybrid" models that build upon existing public and private sources of coverage.

In championing health care reform, however, the Democrats are taking on an issue that was the undoing of President Clinton and the reason the Republicans gained control of the House of Representatives in 2004. Health care is an important issue for Democratic primary voters, but recent polls suggest that health care is not registering nearly as high in the general electorate.

A recent poll found that although most Americans are concerned about health care and the uninsured, there is little enthusiasm for major restructuring of the health care system. Most voters oppose replacing America's pluralistic system with a single-payer plan. The call to replace the employer-based health coverage model with one that would give individuals tax subsidies to buy individual coverage receives only modest levels of support.

Instead, three-quarters of voters favor a hybrid model: expanding the safety net of public insurance programs, providing tax credits to help people buy individual coverage, and requiring employers to provide health insurance to their employees. Less than half of surveyed voters expressed a willingness to have their taxes raised to pay for coverage for the uninsured. (For more information, see "Americans' Views on the Uninsured: An Era for Hybrid Proposals" online.)

Missing issues

What is striking about all of this is that there seems to be an unwillingness among the voters and the candidates to address several issues that are critical to the future of American health care. Those issues include:

  • How should Medicare be reformed to meet its obligations to a rapidly aging population with a higher incidence of chronic disease? It is no secret that the current financing structure—which relies on payroll taxes for the Part A hospital insurance trust fund, and premiums and general revenue for the Part B supplemental insurance program—will not be sustainable as the baby-boom generation reaches Medicare age. Either benefits and eligibility will need to be restricted, or payroll taxes, premiums and general revenue contributions will have to be substantially increased.

    But the argument in Washington is over how to expand Medicare benefits to include prescription drugs, with a 10-year cost conservatively estimated at $400 billion. The bills passed by the House and Senate give lip service to reforming the Medicare program's financing structure, but neither would provide a clear pathway for ensuring that financing is sufficient to meet the increased demands for health care services. Neither of the bills explains which taxes will need to be raised—or what other programs or benefits will need to be cut—to pay for this huge expansion in Medicare benefits.

  • How should limited resources be allocated across the American health care system? None of the candidates appears ready to tell voters that we can't have it all. Would it be better, for instance, to spend $400 billion on providing Medicare prescription drug benefits, as is currently being proposed, or providing health insurance benefits to the 41 million Americans with no coverage at all? How should society make decisions on which health care services will be available to whom and under what circumstances?

    No one likes to think about rationing, but our health care system rations services today based on economic circumstances, access to health insurance coverage or lack thereof, cost-sharing requirements, and the details of insurance contracts that the public has little or no voice in determining.

  • How should the relationship between the federal and state governments be redefined? Faced with the worst fiscal crisis in 50 years, state governments are being forced to drastically cut back on spending on Medicaid and the State Children's Health Insurance Program (S-CHIP). At the same time, the federal government, faced with its own mounting federal budget deficit, is unwilling to pick up the tab for the states.

    Should Medicaid remain a shared responsibility of federal and state governments? How can Medicaid and S-CHIP beneficiaries be protected from bearing the brunt of economic downturns? Should states be given more or less autonomy to design their own programs to provide coverage for their uninsured poor? And if so, what obligation does the federal government have to exercise oversight over such state programs and to provide them with the dollars needed to help them succeed?

Elections and choices

There are no easy answers to such questions. No one has come up with a magic bullet that will allow most Americans to continue to consume all of the health care resources they want without having to raise taxes, cut other essential programs or leave some of their fellow Americans behind.

Politicians from both parties see no advantage in raising such difficult choices in an election. ACP has offered our ideas on many of these issues to the candidates—including comprehensive policy proposals on the uninsured and Medicare reform—but we don't pretend to have all of the answers.

Presidential elections should be about big issues and big choices. They can create mandates that can redefine politics in Washington and break down long-standing political barriers to change. Or they can end up reaffirming the nation's unwillingness to address tough issues that don't yield immediate benefits at the polls.

National security issues are dominating the headlines and political discourse, as they should. But health care security is also vital to the nation's well-being.

Over the long run, the country will lose if this election comes and goes without a serious debate over how to secure adequate health care in an era of limited resources.

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


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