Voting for Health Care

Third Quarter 2004

by Clarke E. Cochran

The November election will not turn on the candidates' position on health care issues. Political scientists generally regard presidential elections as referenda on the performance of the national economy under the incumbent, though foreign policy could overshadow the economy in 2004.

Yet, if I cannot afford health insurance premiums because my wages are not keeping pace, or if doctors discover my spouse's cancer while we are without insurance, these will influence my evaluation of the incumbent's management of the economy.

In this sketch of health care politics, I want to show first that there are clear and important differences between President Bush and Senator Kerry, and second that for Christians who wish to look deeper than the surface issues, differences are far less clear. Indeed, Bush and Kerry share the general American avoidance of the hard questions about medical technology.

Medicare

Medicare's role in the election will turn on seniors' perception of the Medicare Modernization Act (MMA) enacted late last year. Two features of this complex legislation are pertinent: the long-needed addition of prescription drug coverage to Medicare and the alteration of Medicare's structure. The second is ultimately more important, but MMA phases in structural changes over such a long period that they will not affect the 2004 vote.

Prescription drug coverage commenced this summer, so its impact is fresh. Seniors without current drug insurance may purchase the card for a small annual fee and receive discounts from retail pharmacy prices. These cards remain in effect through this year and next, with the full prescription drug benefit to begin in 2006.

The poorest Medicare recipients benefit the most. They receive a $600 subsidy on the drug cards; in 2006, they become eligible for full prescription coverage with waivers of all premiums, deductibles, and co-pays. Although the prescription coverage is technically voluntary, various provisions will make it difficult for other seniors to turn it down. Yet the complexity and expense of premiums, co-pays, and coverage limits will frustrate many middle to upper income recipients, who may not see much advantage to the prescription benefit. Most already have coverage from retirement benefits or private medigap policies. Moreover, there are large gaps in the law's coverage.

Alongside the calculation of benefit is complexity. Even something (seemingly) as simple as a discount card has proved difficult. There are dozens of cards available, with different discount formulas. Seniors have expressed extreme frustration with trying to find out which one is best for them, and they have been slow to acquire the cards, being uncertain of the benefit.

President Bush has less Medicare maneuvering room than Senator Kerry. The President fought hard for MMA and touted its benefits. Senator Kerry left the campaign trail in November to vote against the bill. In my view, the MMA drug benefit does need revision. Both the short-term discount card system and permanent benefit lack cost-control mechanisms. The president and congressional Republicans fought against cost control mechanisms, instead wanting to rely on market forces. Yet the market has proven unable to prevent the prescription inflation that could overwhelm the MMA benefit package.

The design of the permanent benefit also requires reform. As written, the coverage gaps are numerous and confusing. Prescription coverage should be simple and straightforward in order to work best for seniors. Making this change will require significant cost controls to prevent massive overspending on Medicare, controls that are more likely to be advanced by Democrats.

Health Insurance Coverage

The number of Americans without health insurance (and thus exposed to compromised life-chances and devastating financial burden) is a national disgrace. The United States is the only developed nation without insurance for all citizens. Over 15% of the population lacks coverage on any given day. Most live in families with at least one full- or part-time worker, but they work in jobs that do not offer employer-based insurance or with wages too low to afford rising premiums. Public programs, chiefly Medicaid and the Children's Health Insurance Program (CHIP), have not expanded rapidly enough to keep up with the loss of private insurance; indeed, Medicaid and CHIP rolls contracted in the wake of state and federal budget shortfalls in 2002-2004.

Two approaches to reducing the number of uninsured have political appeal. The first, pushed strongly by Senator Kerry and many congressional Democrats, builds on existing public programs. Medicare could be opened to uninsured persons between 55 and 64 years old. The number of children enrolled in Medicaid and CHIP could be increased through more generous eligibility criteria. Parents could enroll in these programs at low or no cost. The Federal Employees Health Benefits Program (FEHBP) could be used as a "pooled risk" device for reducing the purchase price of individual and small-employer policies.

Senator Kerry's campaign estimates that these steps will cover 27 of the 43 million uninsured. This piecemeal strategy represents a strategic shift for the Democrats away from the goal of universal coverage, which seems politically unattainable in the foreseeable future.

President Bush and congressional Republicans embrace a second reform strategy, which would use health savings accounts (authorized by MMA), tax credits for low-income workers' purchase of individual insurance, and federal laws facilitating small employers combining to offer insurance. This strategy relies on the market rather than government. The Bush campaign does not furnish a coverage estimate, but this strategy would reach a far smaller number than the Kerry proposal.

Surely the public-justice imperative is coverage for all citizens with an insurance package that allows access to medical care when needed and without unreasonable financial burden. Both the Kerry and the Bush proposals fall short of this goal, though Kerry's plan comes closer. Yet the enormous current budget deficits prevent significant progress in this direction even with a Kerry victory.

Cost of Health Care; Bioethical Issues

To the average voter, the escalating cost of health care weighs more heavily than coverage issues. Cost is also the most difficult to understand and the most complex to solve.

Senator Kerry takes an aggressive approach to cost control, and it is unlikely that most measures would pass Congress in 2005. First, he would shift some of the cost of health insurance premiums from employees and employers to the federal government through a "premium rebate pool" to cover high medical bills. Second, he proposes using federal regulatory and purchasing power to reduce prescription inflation. Third, he suggests a variety of adjustments to reduce the cost of medical malpractice insurance. Fourth, he relies on incentives for medical technology to reduce expensive medical errors and reduce administrative costs. Finally, he would create a variety of unspecified health promotion and disease prevention programs.

President Bush's efforts to restrain health care cost inflation are more modest. He relies on malpractice insurance reform, chiefly in the form of procedural reforms and limits on recovery of punitive damages. He also believes that greater use of health savings accounts will reign in cost increases. Like Senator Kerry, President Bush also proposes a variety of quality improvement initiatives.

None of the measures proposed by either candidate or all of them together are likely to have much impact on the rising cost of medical care. The chief culprit is ever more expensive medical technologies and the highly paid personnel needed to implement them.

Hotly debated bioethical issues, such as embryonic stem cell research and cloning, reveal clear differences between the candidates. President Bush's support for strictly limited research on embryonic stem cells and for a federal ban on all cloning contrasts with Senator Kerry's acceptance both of cloning for research purposes and of wider access to embryonic stem cells. But these issues do not rank high with most voters, though Christians should be especially attentive to the moral cost of such research.

Deeper Issues Not on the Agenda

Advances in medical technology are the driving force behind health care cost increases in what is by far the most expensive health care system in the world. Each new discovery multiplies the number of treatments given to the average patient, fueling health inflation. Slowing the research and development (much of it government funded) that produces such "breakthroughs" would better steward public and private resources. But this is heresy to Americans, who place more faith in medical progress than do the citizens of other nations.

American culture thrives on the hope generated by "medical breakthroughs." More research will lead to more cures. So we like to believe. But life is a terminal condition, and death is not the greatest enemy in Christian theology. Yet Christians are not opposed to healing, and many technical advances result in cures and better health. The Christian challenge is to define appropriate limits on medicine and to discover medicine's place advancing the common good. Yet the American electorate seems disinclined to hear of limitation, and the candidates of both political parties are only too happy to promote limitless dreams.

[Clarke E. Cochran is Professor of Political Science at Texas Tech University.]