Health Care and the 2000 Elections

Fourth Quarter 2000

by Clarke E. Cochran

The issues are familiar: 

• how to make health insurance available to the 44 million Americans currently uninsured (1 in 5 of those under age 65);
• what regulations (if any) to impose on the new corporate health care entities, usually designated "man-aged care companies";
• how to ensure the viability of Medicare; and
• how to respond to newly emerging technologies (for example, new pharmaceuticals, uses of fetal tissue, and the manipulation of the human genome).

The size and technical complexity of health care make it daunting to develop a brief list of Election 2000 priorities. Nevertheless, the basic issues and alternatives can be concisely stated.

Extending Insurance Coverage

The number of Americans without insurance (and therefore with compromised life-chances and potentially devastating financial burdens) constitutes a national disgrace. The number rises by one million yearly, even as the economy prospers. The United States is the only developed nation without universal coverage. Most without insurance work substantial hours, but in jobs not offering employer-based insurance or for wages too low to afford insurance. Public programs, chiefly Medicaid and the Children's Health Insurance Program (CHIP), do not expand rapidly enough to keep up with the loss of insurance; moreover, few working adults qualify.

There is no lack of proposals for gradually expanding coverage, but no consensus has formed around any incremental plan. Fear of increasing government expenditures stymies creativity and coalition building. There are two basic options.

1. The first uses existing public programs. Medicare could be opened to uninsured persons between 55-64 years old. The number of children enrolled in Medicaid and CHIP could be increased. Uninsured parents of Medicaid and CHIP children could be permitted to enroll at low or no cost. The Federal Employees Health Benefits Program (FEHBP) could be used as a "pooled risk" device for reducing the cost of individual and small-employer policies. A cautious version of this strategy forms the core of candidate Gore's health care platform.

2. The second strategy is to provide premium subsidies, tax credits, or vouchers to subsidize the purchase of insurance either on the open market or through employers. Because these strategies rely on the market rather than on government and because individuals would make voluntary decisions about coverage, Republicans have found them attractive, and candidate George W. Bush has proposed a variation.

The first and second approaches are not mutually exclusive, and elements of each could be employed in a post-election compromise. Rapid implementation and aggressive expansion of public programs (CHIP, Medicaid, Medicare) brings America closer to health care justice in the near term. But the most generous, politically feasible combination of these proposals extends coverage to fewer than half of the currently uninsured. Moreover, each option or combination leaves in place the high degree of fragmentation in the health care system. Both public and private insurance present a bewildering number of options and make processing claims very expensive. Building on a fragmented system, the Gore option, or, adding even more complexity, the Bush option, adds complexity, high administrative cost, and the tendency for higher risk persons to be inadequately insured.

The only ways to achieve universal coverage without unacceptable variations in care and financial risk are either to establish government as the "single payer" for basic, comprehensive health insurance or to establish a very limited number of standard private insurance policies from which each citizen must choose (with mandatory contributions by employers). Neither presidential candidate nor political party seriously proposes these approaches.

Medicare Reform

Social commitment to the increasing number of elderly citizens requires a financially secure Medicare program. Moreover, relieving the intolerable burden that escalating prescription drug costs (not covered in the current Medicare program) place on low- and moderate-income seniors is a pressing need. Finally, Americans must devise a system of long-term care insurance for the feeble and chronically ill aged. These are matters of justice for vulnerable citizens and of keeping the aged within the moral structure of American community. Both political parties and their presidential candidates explicitly recognize all three priorities, and congressional leaders have devised a variety of proposals to meet these needs.

Democratic proposals for Medicare reform tend to rely on uniform benefits for medical care and pharmaceuticals. They have pushed plans that guarantee all recipients a standard set of benefits and that rely on income-related premiums for a government-administered prescription drug benefit. Republican plans lean toward the private insurance market. They advocate defining how much the federal government will contribute toward health insurance for the elderly, and then allowing them to choose from among a variety of insurance plans. Similarly, prescription drug benefits would be voluntary and privately insured, with federal subsidies for the poorest recipients. For assuring long-term care, both parties limit their suggestions to government financial encouragement of private insurance.

Reliance on markets does seem appropriate in the fledgling business of long-term care insurance. However, the potential for medical costs generally and for prescription drug costs specifically to overwhelm many seniors does suggest the value of uniform national policy and for treating all the elderly alike insofar as possible. Weakening the federal commitment to a uniform insurance program for the elderly could lead to market segmentation of the older and sicker into less adequate plans than the younger and healthier among the elderly.

The Challenge of Scientific Advance and New Medical Technologies

These are among the deepest and most difficult of issues confronting the nation, because they touch directly on the question of human life, on its meaning, and on the extent to which humanity is free to alter itself. Physician-assisted suicide, use of fetal tissue from abortions for medical research and for disease treatment, and the none-too-distant prospect of direct manipulation of the human genome illustrate the intensity of these challenges. Christians are rightly cautious about these developments, about medical technology's infinite expansive-ness, and consequent policy implications. Each presidential candidate manifests a similar caution, and these issues are most likely to be fought out in the relative obscurity of congressional debates and National Institutes of Health priorities during the next decade.

Managed Care Regulation

Health Maintenance Organizations (HMO) and other forms of "managed care" are hot topics in election year 2000. Despite thousands of anecdotes, there is no systematic empirical evidence that man-aged care is of lesser quality or more harmful to patients than the fee-for-service system that it replaced. Yet the candidates and parties vie strenuously for leadership in responding to clear public-opinion demands for restraint and regulation of these businesses. Given the lack of strong and systematic evidence of abuses, prudence dictates proceeding slowly and cautiously, leaving regulation to the states and to the enterprises themselves.

[Dr. Cochran is Professor of Political Science and Adjunct Professor of Health Organization Management at Texas Tech University in Lubbock, Texas.]

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A Second Black Death Looms in South Africa

R.W. Johnson, in a recent commentary in The Times (London, 8/29/00), commented that the World Aids Conference in Durban, South Africa in July may have begun to awaken the wider world, if not enough South Africans, to an emerging crisis of immense proportions.

"No urbanised society has ever had to deal with an epidemic like this: the Black Death seared rural medieval Europe and the other African countries suffering from the Aids pandemic are essentially rural societies. These village societies are more self-contained and less complex than South Africa's: some villages may be wiped out, others left untouched. . .

"Cities are different: there's no containing an epidemic that has already infected 20 per cent of adults in Johannesburg and 30 per cent in Durban. "The cemeteries in Soweto can't cope," one is told. "They used to bury adults at the weekend and children during the week. Now adults get buried whenever a space can be found." But we've seen nothing yet. The only solution will be to build a large number of crematoriums, since there will never be enough spare urban land for graveyards....

"As Aids progresses, other spending is squeezed by medical and burial expenses—and why should someone who knows they are infected bother about paying rates [rents]? Indeed, one reason for the condition's continued spread often seems to be the irresponsible behaviour of those who know they are infected but continue to engage in multiple sexual contacts. . . . [C]onfronted by crisis and death on such a scale, most take refuge in simple denial. Many African men still insist that Aids doesn't exist and it is very noticeable that Aids deaths are almost invariably passed off as something else or simply not mentioned."