Health Care: A Litmus Test

By Richard Lacayo

If the next president decides to attempt it, health-care reform will be the space program of the early 21st century, a massive government undertaking, but this time with earthbound targets and no big heroes. No glamorous moon to go to, no John Glenn. All the same, in a nation where 44 million people don't have medical insurance, and where a lot of the insured aren't happy with the care they get, there are probably more people rooting for an HMO fix than were ever waiting for a lunar landing. When voters tell pollsters that health care is among their top election-year concerns, that's because the frailty of the body is one issue that touches everybody--aging baby boomers, their vulnerable children, their fragile parents.

Because of its universal reach and its complexity, the problem of health care is a useful way to measure the political temperaments of the four major candidates. For Al Gore and Bill Bradley, the issue is irresistible but also bewitched. The good news for them is that Democratic primary voters want to hear about health care, which means Gore and Bradley can get an early start on identifying a big issue for November. In a sense, when Bill Clinton last week offered his own 10-year, $110 billion plan to extend coverage to more of the uninsured, he extended coverage to Gore as well. Whatever fate his plan meets in Congress, where the patient's bill of rights languishes in conference, Clinton's proposal guarantees that health care will be part of the public conversation through the spring, and that is a discussion in which Democrats know how to talk the talk.

As a sign that the talk is already well under way, the Health Insurance Association of America, which sponsored the "Harry and Louise" ads that helped derail the Clinton plan for universal coverage in 1994, rolled out a new series of ads last week. But now the fictional couple is in favor of an insurance-industry initiative that would expand coverage of the uninsured through broadened federal programs and changes in the tax code. "It was important to get this advertisement out there at this formative stage of the election year," says HIAA president Chip Kahn, a former legislative aide to Newt Gingrich.

But voter expectations also require Gore and Bradley to make concrete proposals, so each of them is providing the other with a target to shoot at. The two Democrats have offered big, detailed plans, but each has a different emphasis. Bradley's is big but not so detailed. In its main element, it would abolish Medicaid, which provides coverage for the poor, and channel them instead to enroll in the insurance program already available to federal employees. Bradley would also offer the poor tax breaks and subsidies to help pay for insurance. Gore's plan is detailed but not so big. He aims to provide every child with health care by 2005, but he proposes to do that mostly by expanding the existing Child Health Insurance Program (CHIP), a federal program for uninsured children of low-income families. Both men would offer a prescription-drug subsidiary to everyone on Medicare.

For Bradley, health care is at the core of his campaign, and not just because his irregular heartbeat is a reminder of his own need for regular checkups. It provides him with the opportunity to lay out a massive government enterprise, one of the "big and bold ideas" that define his image of himself as a true Democrat--truer at least than the small-stepping Gore, who wants to start reform by insuring a portion of the uninsured first, then expand the pool of those covered over five years. At every campaign stop, Bradley compares himself to Franklin Roosevelt and Lyndon Johnson, Presidents who built spacious national institutions, Social Security and Medicare, with one mighty effort. "Lyndon Johnson didn't say, 'Let's give Medicare to 20% of the elderly this year and 30% next year,'" he says.

This is the kind of talk that makes Gore wince, and not just because the big gesture is not part of his nature. Having suffered collateral damage from the collapse of the Clintons' health-care initiative six years ago, he knows something about the art of the possible. He does not believe Bradley's expensive plan can make its way through any Congress likely to emerge from the next election. And Bradley's fuzzy numbers mobilize Gore's wonkish side. For weeks he has scored heavily against Bradley in New Hampshire and Iowa by shaking his head mournfully over the most controversial part of Bradley's plan--to abolish Medicaid and then provide each former recipient with as little as $150 a month to buy insurance in the open market.

In Ottumwa, Iowa, last week, Bradley was asked about Gore's claim that the $150-a-month figure would not be enough to buy new coverage anywhere. Bradley's answer was, "The number is not the point. The point is, Do you have a goal, and do you have a plan that can get us there?" Don Kirchner, 53, a burly, bearded man with two gold hoops in his left ear, is a former mental-health worker on disability, and he wasn't buying it. "Anyone running for President who says, 'Don't worry about the numbers, trust me'--I'm sorry, I'm still skeptical."

As if to second that idea, Bill Clinton's plan last week, in its focus on enlarging existing programs, endorsed the Gore approach. A prelude to his final State of the Union address this week, the President's health-care proposal was, in size and detail, a project of the kind that lame ducks love to launch as proof that they're not dead ducks. The biggest health-care initiative since Medicare was enacted in 1965, its main elements are a $3,000 tax credit for people facing such long-term expenses as nursing-home care and a $76 billion proposal to insure 4 million parents of the children who receive health coverage under Medicaid and CHIP.

Bradley, however, has his own argument with CHIP, the central engine of Gore's plan to cover children. It manages to enroll only about 10% of the eligible children in each state. In his plan Gore would expand CHIP's eligibility standard, but he offers nothing about how to go about actually gathering in more of the eligible kids. And while Gore claims that extending coverage to children is merely the first step in a larger campaign for universal coverage, Bradley likes to make clear that Gore's 10-year budget proposal contains not a penny for taking that second step.

For George W. Bush and John McCain, health care really is a problem, the one that dare not speak its name. Neither man supposes he can avoid the topic all the way to November, but for now each talks about it with shrugs and mumbles. How to broaden coverage is a tough problem for Republicans to solve within the terms of the conservative taboo against government spending programs. Even when Bush admitted to one audience recently that uninsured working people were "a big problem," he added that "I'm worried about a plan that says we'll just have the national government come up with the answers."

If anything, the issue has taken both of the Republican front runners a bit by surprise. Republican primary voters are more conservative than the general electorate and were not supposed to care as much about health issues. Instead, both men have been getting hit regularly with voter questions about insurance, prescription-drug subsidies and the rough handling that some patients suffer from HMOs.

Bush does have positions on some of those issues, though sometimes vague ones. He favors medical savings accounts, which would allow Americans to buy catastrophic health insurance and set aside other money for health care in private, tax-sheltered savings accounts. He also talks about wanting to strengthen Medicare and improve the access that Medicare patients have to affordable drugs by providing more choice and more private-sector alternatives. What he doesn't have yet is a plan for doing any of that.

And on the campaign trail, Bush is almost grudging in his discussion of health care. In New Hampshire two weeks ago, at a public forum in the small town of Londonderry, a woman stood up and made an impassioned plea on behalf of the uninsured for Bush to put health-care reform at the top of his agenda. Bush's brisk reply bought audible gasps from the audience: "Some of those uninsured are just able-bodied folks who don't want to buy health insurance." In fact, he has a point. But the blunt way he introduced the notion, with the implication that the willingly uninsured are a substantial chunk of the uncovered population, made him sound like Ronald Reagan insisting that trees were a major cause of air pollution.

McCain gave a health-care speech in December in which he proposed to use tax incentives to provide medical-savings accounts. He also said he would spend a billion dollars a year to shore up long-term care and fix the faltering Veterans Administration health system. Like Bradley, McCain likes to cite health care as another reason for campaign-finance reform. "We can sit down in five minutes and come up with a reasonable patient's bill of rights," says McCain. "Why can't we? The Democrats are captives of the trial lawyers, and the Republicans are gridlocked by the HMOs and the big insurance companies."

McCain also says he wants to provide nothing less than universal health-care coverage, a position that sets him well apart from most other Republicans. But as part of his famous candor, he admits that he is not yet sure just how to do it. That's partly because, as a conservative, he balks at the main conceptual hurdle of the health-care problem, namely that Washington will have to be part of any solution. But all four candidates, even the Republicans, are aiming to end up in Washington, where voters will have sent them to solve the big problems, even maybe to shoot for the moon.

--Reported by Jay Branegan, Jay Carney, John F. Dickerson, Tamala Edwards and Eric Pooley

With reporting by Jay Branegan, Jay Carney, John F. Dickerson, Tamala Edwards and Eric Pooley