Poll after Poll shows that Americans don't like HMOs. Yet any "Universal Coverage" that they come up with will have to "HMO" or break the Country.
January 14, 2004 New York Times
THE ISSUES: HEALTH INSURANCE
Democrats See a New Urgency in Health Care
By ROBIN TONER
ES MOINES, Jan. 13 — Ten years after the political collapse of President Bill Clinton's health plan, the Democratic Party's presidential candidates are proposing, once again, major new programs for guaranteed, affordable health insurance, setting the stage for one of the starker contrasts with President Bush in the general election campaign.
The nine candidates for the Democratic nomination disagree, often sharply, on how they would expand coverage, how they would pay for it, whose plan would work best and how many of the more than 43 million uninsured Americans they would try to reach. But beneath these disagreements is a consensus that a health care crisis of soaring costs and declining coverage has returned.
Here in Iowa, affordable health care is at the center of the middle-class populism most Democrats are advancing in campaign commercials and on the stump. At a speech here this morning, Senator John Edwards, the North Carolina Democrat newly energized by The Des Moines Register's endorsement on Sunday, declared that it was time to "make health care a birthright for every child born in America, for the first time in American history."
Representative Richard A. Gephardt of Missouri, who has built his campaign around a $214-billion-a-year plan to cover every American, describes it as nothing short of a moral issue. Senator John Kerry of Massachusetts says health care legislation would be the first bill he would send to Congress as president.
One of Mr. Kerry's most frequently broadcast commercials in Iowa features a family in which the husband lost his job and the wife had breast cancer. "To keep her health insurance, she had to keep working right through the chemotherapy," Mr. Kerry declares. "We need to change that."
And Howard Dean, the former governor of Vermont, promotes his record of achieving near universal coverage of children in his state and often concludes, "This is not some crackpot liberal idea from Vermont — Harry Truman put universal health insurance in the 1948 Democratic platform."
The idea of guaranteeing health insurance to every — or nearly every — American has deep roots in the Democratic Party. But the failure of the Clinton health plan in 1994, amid a barrage of accusations that it would constitute a big-government takeover of the health care system, left many Democrats gun-shy of the issue for the rest of the 1990's.
This year, "the thing that strikes you is the progression we've made," said Kenneth E. Thorpe, a former Clinton health adviser who is a professor of health policy at Emory University. Most of the Democrats try to avoid the wholesale restructuring of the Clinton plan, which roused fears among many insured Americans that they would have to settle for less so that everyone could be covered.
Still, "they're all pretty bold plans," Professor Thorpe said.
Most of the leading Democratic candidates' health plans are many times more expensive than the main Bush proposal for the uninsured, an $89 billion, 10-year package of tax credits, he noted.
Bush administration officials and Republican strategists say they have no plans to cede the issue to the Democrats. They say the president will campaign as having already delivered the biggest expansion of Medicare in 38 years, adding prescription drug benefits for the elderly, and can thus be trusted to improve the health care system for all. "The question now is who has the track record," a Bush campaign adviser said.
So far, Democratic candidates seem uncowed by the president's Medicare accomplishments; Mr. Edwards, for example, on Tuesday described the prescription drug bill as simply shipping "billions of your dollars into the H.M.O.'s." But in a general election campaign, Republicans are convinced that the legislation will be a big advantage.
Administration officials also reject the idea that spending more federal money is the only — or the best — way to cover more uninsured Americans. They say that some of the president's proposals, like limiting jury awards in medical malpractice suits, will hold down health costs and make insurance more affordable. At the same time, the president's tax cuts and tax-free savings accounts give people more money and flexibility to meet their families' needs, administration officials say.
Still, Mr. Bush is expected to outline more aggressive policies this year to help the uninsured and the underinsured, and the issue could be front and center this fall. "It has the potential to both mobilize voters and persuade voters," said Celinda Lake, a Democratic pollster. "You can get African-American voters, liberals, very fired up, but the flip side is, it also persuades swing voters."
Bill McInturff, a Republican pollster, said one of his surveys last month found that "affordable health care" ranked second, just below the economy and jobs, and above terrorism and national security, when voters were asked to list their most important issues. It is particularly important among women, Mr. McInturff said.
The Democratic debate over health care is inextricably linked to the debate over Mr. Bush's tax cuts, with most of the candidates advocating using at least part of that money to finance their health care plans. Mr. Gephardt and Dr. Dean have proposed repealing all of the Bush tax cuts, including those for the middle class, and redirecting the money toward health care. (Dr. Dean, whose health plan is less expansive than Mr. Gephardt's, would also use some of the Bush tax money for deficit reduction and other areas.)
Their support for total repeal has drawn increasing fire from several of their rivals, who say it would be unfair to eliminate the tax cuts for the middle class. But Mr. Gephardt has argued in recent days that his health plan is a better way "to put more money on the kitchen table of middle-class families," stimulating the economy, lowering employees' premiums and providing, for the first time, true health care security.
Mr. Gephardt, in many ways, set the pace for the Democrats last April when he released a broad proposal that requires all employers to offer health coverage to their workers, and provides them with major new tax credits to do so. The public programs — Medicaid, the State Children's Health Insurance Program, or Schip, and Medicare — would be expanded to insure those not covered through work, and the Gephardt campaign estimates the plan would ultimately come close to universal coverage.
Mr. Gephardt calls his proposal "Matt's Plan," in honor of his son, who struggled with cancer as a child and is now well. Mr. Gephardt says Matt was saved by aggressive, experimental treatments that would not have been available if his family did not have good health insurance.
Dr. Dean, whose physician persona is at the heart of his campaign, says his plan is the most politically realistic, because it essentially expands the existing system. "My plan was designed with Harry and Louise in mind," he says, alluding to the insurance industry commercials against Mr. Clinton's plan. The advertisements featured a couple in their 40's expressing their fears over shadowy bureaucrats taking control of the health care system.
Dr. Dean says his first priority would be to get people covered, not to reform and restructure the system, which the Clintons proposed. "We can have a big fight later," he says. In the meantime, he would expand Medicaid and Schip, intending to to cover every child and young adult in a low-to-moderate-income household and use tax credits to help others buy insurance.
Mr. Edwards also puts a heavy emphasis on children; he would require that everyone younger than 21 have insurance and give parents new assistance to provide it. So do Gen. Wesley K. Clark and Senator Joseph I. Lieberman of Connecticut, who advocates a "Medikids" program that would offer families a variety of private plans, with premiums based on income.
Most of the candidates talk about the health care issue as not only covering the uninsured, but also as lowering costs for those who have insurance. Mr. Kerry, for example, proposes a federal program to reimburse employee health plans for their most expensive, catastrophic cases, which would, in turn hold down premiums, he says.
"The problem with health care in America is not just bringing in 43 million Americans who don't have insurance at all," Mr. Kerry has said. "The problem with health care in America is reducing costs for the 163 million Americans who get their health insurance in the workplace, and for the others who get it privately. And what's happening in America is every year the premiums are going up, the co-pays are going up, the deductibles are going up, the benefits are going down, and Americans are just fed up with a system that seems out of control."
Carol Moseley Braun, the Rev. Al Sharpton and Representative Dennis J. Kucinich of Ohio all advocate some form of national government-run health insurance.
Health care experts say it is not surprising that the issue has re-emerged this year. Health spending rose 9.3 percent in 2002, the government reported last week, the largest increase in 11 years. Premium costs and out-of-pocket spending by consumers are climbing as well, reflecting greater pressures on those with no insurance or insufficient insurance. Moreover, the fiscal crisis in many states has forced cutbacks in their health programs.
Even so, experts say, the Democrats' proposals will be shadowed by the deficit. Some health advocates have long said they see a potential deal in Congress, between the Democrats who would like to see the public programs cover more people, and the Republicans who advocate a tax credit approach. But, they add, that would be hard with the current budget constraints.
Copyright 2004 The New York Times Company |
