Presidential prescription: How to fix health care
■ Everyone agrees there are a few glitches in the U.S. health care system. But the two leading presidential candidates have opposing ideas about what should be done.
By Joel B. Finkelstein — Posted Oct. 4, 2004
When it comes to health care issues, physicians will face two very different choices as they go to the polls in November to elect the next president.
"There couldn't be a bigger contrast between domestic policy priorities than the issue of health care in this campaign," said Christopher Jennings, president of Jennings Policy Strategies in Washington, D.C., and a senior White House health policy adviser during the Clinton administration, speaking at a recent media event.
President Bush's proposals have focused on minimizing government intervention and freeing market forces to create solutions. Sen. John Kerry (D, Mass.) has placed more emphasis on using government resources to reduce barriers to health care for the poorest Americans.
"Both of these candidates have focused on good solutions related to where their personal beliefs are," said Jacque Sokolov, MD, chair and senior partner of Sokolov, Sokolov, Burgess, health care consultants in Scottsdale, Ariz.
Health care is generally not at the top of most voters' priority lists, but this year it is not far behind the economy, Iraq and the war on terrorism, said Christopher Borick, PhD, an assistant professor of political science and director of the Muhlenberg College Institute of Public Opinion in Pennsylvania.
Health issues are playing prominently because the candidates haven't been able to gain an advantage on other top-tier issues, experts said.
In establishing his health care platform, Bush is fighting an uphill battle, not only because Democrats have historically taken the lead on such issues, but also because costs continue to rise and the number of uninsured Americans has jumped again, said Daniel Gotoff, vice president of Lake, Snell, Perry & Associates, a Democratic polling firm in Washington, D.C. "The fundamental obstacle that the Bush-Cheney campaign has in talking to voters about this issue is that they have to try to convince them that what they're seeing around them is not the case," he said.
But the president does have a record to run on, mainly based on last year's Medicare reform law.
By contrast, Kerry has proposed an ambitious and expensive plan for system reform, but hasn't come out front on any health issues recently.
"The Kerry campaign has said, 'OK, what's the problem here?' And they've come to the conclusion that there's not enough government intervention in health care," said Megan Hauck, deputy policy director for the Bush-Cheney campaign, also at the media event.
Over the past few months, Bush and Kerry have laid out their proposals to address problems of particular interest to physicians.
Both candidates have acknowledged the severity of the medical liability crisis but have suggested different approaches.
Bush favors establishing a monetary cap on damages for pain and suffering as part of a larger package of tort reforms that also would ease liability concerns for other industries.
"HHS came out with a study that said we waste between $60 billion and $108 billion because of frivolous lawsuits, that this is money going out of the system, not to take care of patients, but to pay off personal injury lawyers," Hauck said. "The president has a proven, common-sense medical liability reform proposal that has worked in the states."
Campaign officials argue that capping awards will discourage trial lawyers from filing meritless lawsuits that are blamed for driving up liability premiums.
The AMA has made a $250,000 cap on noneconomic damages its main legislative priority. AMA officials point to California as an example of the strategy's success.
But not all experts agree that such caps would slow the growth of premiums, Borick said. Kerry has opposed the caps but offered strategies to target the lawyers who bring frivolous medical malpractice lawsuits.
The Kerry campaign has proposed implementation of a federal requirement that a medical expert review a case before a lawsuit is filed, and setting penalties for lawyers who repeatedly file frivolous suits. His plan also calls for barring punitive damages except in the most egregious cases and establishing alternative forums for dispute resolution.
But similar sanctions are already on the books on state and federal levels and have had little effect on frivolous lawsuits or physicians' liability premiums, said Donna Klein, head of the health care law group at McGlinchey Stafford in New Orleans.
Whoever wins the election this fall will face a crisis brewing with Medicare physician payment. The federal government has predicted sharp cuts in coming years.
Both candidates have supported legislative efforts to fix the flaw in the Medicare physician payment formula, but neither has included such a proposal in his campaign platform.
Instead, much of the Medicare debate has focused on the prescription drug program. Republicans hail the drug benefit as a huge accomplishment, but, fairly or unfairly, the law has yet to impress the public. Recent surveys show most seniors have taken a dim view of it.
"Voters believe that pharmaceutical companies and the insurance companies ... are the biggest beneficiaries under this new law," Gotoff said.
Survey respondents said drug and insurance companies would get the most benefit, while a small percentage thought seniors and their physicians would be helped the most.
"The average individual didn't view it as an incremental strategy. They just viewed it as a failed policy because it wasn't robust enough," Dr. Sokolov said. "There is just a disconnect between what people thought they were going to get and what was in that bill."
That perception means that the Bush campaign is unlikely to get much mileage out of the law in trying to establish its health care credentials, Borick said.
The Bush administration has resisted making any changes to the measure, while Kerry has adopted the relatively popular position that the law should be modified to legalize drug importation.
Physicians struggle with the importation issue. They want their patients to have access to affordable drugs, but many worry about the safety of medicines from abroad.
Kerry also wants to allow Medicare to negotiate lower drug prices from pharmaceutical companies.
"What the Kerry campaign would clearly like to do is cherry-pick and find two or three things that are wrong with the bill and say, 'This typifies the whole bill,' " said David Winston, president of the Winston Group, a Republican polling firm in Alexandria, Va. "The public may not see every single thing that they wanted in it. That is a very different standard than whether they think progress was made."
But Medicare reform is about more than just prescription drugs. The law included a shift in emphasis that would make the program adapt to the medical community's evolving ability to better manage patients' chronic conditions.
Bush has touted his administration's effort to promote disease management, and Kerry also has promised to encourage such changes.
The recent announcement that the number of uninsured Americans has risen to 45 million highlights another stark difference between the candidates -- the scope of their proposals to address the problem.
Kerry's promise to expand public coverage to all children, subsidize premiums for low-income people and offer incentives to get small businesses to offer health benefits could reach an estimated 26.7 million uninsured people. But the cost is high: $653 billion over 10 years.
On the other hand, Bush would like to change the tax code so that people could get the same tax break for buying individual health insurance as they do currently through employers. He also would like to see association health plans regulated by the federal government instead of the states. His proposals are expected to reach an estimated 2.1 million uninsured Americans at a cost of $90 billion over 10 years.
But Bush faces some stiff opposition to his proposals.
"Association health plans [are] the only policy that I've seen in the history of mankind that uniquely brings together governors, insurers, insurance commissioners, providers and consumers against the policy," Jennings said.
Those groups have complained that AHPs would destabilize the insurance market and actually raise premiums.
While Bush's strategy would not require any money not already included in pending budget proposals, Kerry's plan relies on the repeal of a portion of Bush's tax cuts for funding. His proposal also counts on savings gleaned from the system through the implementation of electronic medical records.
"Sen. Kerry believes that there will be significant savings over 10 years in the adoption of these advanced technologies, to the tune of approximately $200 billion," Dr. Sokolov said. "Many people think those numbers won't go very far in Congress because they're unrealistic."
Even though his plan is less sweeping than the changes proposed during the Clinton administration, Kerry still likely would face difficulty gaining support, given the current state of the budget, experts said.
Both candidates also have proposed tax credits to help people purchase health insurance. But their approaches differ fundamentally.
Kerry's plan would target tax credits to low-income people who do not have health insurance.
Bush's strategy is to help low-income people purchase individual coverage, specifically high-deductible plans linked to health savings accounts, regardless of whether they already have insurance through an employer.
The AMA supports tax credits that are advanceable, refundable, inversely related to income and generous enough to allow most people to afford health insurance.
Both campaigns are offering valid approaches; it just depends on your perspective, Dr. Sokolov said.
"If you were an individual who fundamentally believed that there should be less government intervention in health care, you would be very much focused on the President Bush perspective. If you felt you wanted to enfranchise 26 million more people because we don't have affordable health care in this country, you'd embrace the Kerry proposal," he said.
In the end, most voters will evaluate the campaigns' platforms with one question in mind, Winston said.
"Will this improve the quality of my health care -- not the health care system -- my health care?"