As they run for the presidency, candidates George W. Bush and Al Gore are positioning themselves behind battle lines that have been built by their party's generals during the last four years.
Texas Gov. Bush, the presumptive Republican nominee, has chosen the decidedly free-market path favored by the Republican congressional leadership. Vice President Gore, the presumptive Democratic nominee, is choosing the limited activism, or "incrementalism," that has marked President Clinton's administration since the failure of national healthcare reform in 1994.
But as they approach their parties' nominating conventions, which begin next month, they have yet to draw up creative new offensives on healthcare. Bush and Gore have preferred to stick to the weapons that so far have fought the two parties to a tactical draw on such pressing healthcare issues as extending coverage to the uninsured, reforming Medicare and helping seniors pay for prescription drugs.
"These are two guys on surfboards riding waves that others have created--both trying to assert some credit for the size and shape of the wave," says Robert Reischauer, president of the Urban Institute in Washington and a former head of the Congressional Budget Office.
"My view on both candidates is they are incrementalists," says Richard Roberts, M.D., president-elect of the American Academy of Family Physicians and a professor of family medicine at the University of Wisconsin in Madison. "Thus far, there's nothing really dramatic in what either of them has proposed. They're just nibbling around the edges.
"With an incremental approach, you can throw out little bones through the course of the campaign. That gets your opponent on the defensive, when you're proposing a little new thing every week."
No big plans. It's a far cry from the drama of the 1992 campaign, which saw then-candidate Clinton promise universal health insurance coverage, or 1996, which saw Democrats accuse Republicans of raiding Medicare to pay for tax cuts for the wealthy.
Healthcare's shrinkage to a tactical weapon in campaign 2000 from its defining role in the two previous presidential campaigns could be explained in part by voters' tendency to look past the issues when choosing a president.
Robert Blendon, a professor of health policy and political analysis at Harvard University, says people cast their votes based on leadership and character.
Meanwhile, the country's relative prosperity and a federal budget surplus has found lawmakers in the unfamiliar position of urging expanded spending programs, as opposed to the austerity of past years.
That prosperity also has diminished the calls for a radical change in the nation's healthcare system, however. With unemployment low, fewer people feel their employer-paid health coverage is threatened. Without a looming crisis, lawmakers are not likely to rock the boat.
Even Medicare, feared to be on the verge of bankruptcy at the time of the last presidential election, is as healthy as it has ever been. When Clinton defeated former Sen. Bob Dole in 1996, the Medicare Hospital Insurance Trust Fund was projected to go bankrupt in 2001.
This year, Medicare will spend $228.4 billion, according to the annual report of the trustees of the Medicare trust fund. That will rise 81.7% to $415 billion by 2009, according to the report.
Now, thanks to the Balanced Budget Act of 1997, a slowdown in healthcare inflation and increasing Medicare payroll tax collections, the trust fund won't go broke until 2025. That has driven Medicare reform out of the headlines and brought a Medicare prescription drug benefit to the fore.
But as an issue, healthcare still ranks high. A survey by the Harvard School of Public Health and the Kaiser Family Foundation, to be published in the July/August edition of the journal Health Affairs, found that healthcare was second only to education in voters' rankings of important issues.
Education was cited as the most important issue by 29% of 1,257 registered voters and healthcare by 28% in the poll conducted in December 1999.
But the voters who consider healthcare a top issue aren't unified in their concerns. The Harvard/Kaiser survey found that two-thirds of respondents were concerned with healthcare costs, the uninsured and managed-care reforms. One-third, a disproportionately older population, was more concerned with Medicare.
As a result, no single healthcare proposal is likely to unify the electorate, yielding the piecemeal, tried-and-true proposals being offered by the candidates.
What's more important, says Blendon, is that candidates have a plan to deal with the issues that voters consider important.
"Issues move people most . . . when one party is against doing anything and one party wants to do something," he says.
Little difference. But if Bush and Gore are shielding themselves behind existing battle lines, those lines are gradually drawing closer together. While sticking to their parties' guns on Medicare, for instance, both Bush and Gore want Medicare to help cover seniors' prescription drug costs, want Medicare reform to ensure continued solvency of the program, want to find new ways to cover uninsured people and want to offer new protections for managed-care enrollees.
"There's more common ground than battleground," says Richard Pollack, executive vice president of the American Hospital Association.
On many of Republicans' most vulnerable healthcare issues, Bush has inoculated himself, either by drafting healthcare proposals endorsed by moderate and conservative policy groups or by taking stands in conflict with many of his fellow Republicans. Managed-care reforms that give patients the right to sue took effect in Texas while Bush was governor, something many congressional Republicans, particularly in the U.S. Senate, have opposed.
Bush also has put forward a plan to cover the uninsured, relying on tax credits, business purchasing cooperatives, the State Children's Health Insurance Program and medical savings accounts.
Gore charges, however, that Bush has done little as governor to extend coverage to the uninsured. Bush responds that the ranks of the uninsured grew nationally during the eight years of the Clinton presidency, although he has not talked about any initiatives for covering the uninsured.
The difference between the two is in degrees. On prescription drugs, for example, Bush wants seniors to buy private-sector plans covering drugs, with Medicare picking up the tab for low-income seniors and those with high drug costs. His plan is much like that of his GOP allies in Congress.
Gore backs the Clinton plan, which would cover half the prescription drug costs of all seniors who purchase coverage through Medicare.
The rhetoric about the differences has already begun to bubble to the surface. Democrats charge that the Republican plan isn't a Medicare benefit at all, but a welfare plan for the poor and an insurance plan for all other seniors.
They also question whether insurers will even offer such plans.
Richard Sorian, a former HHS official who is a policy analyst at Georgetown University and a consultant to the Gore campaign, describes a stand-alone drug benefit for seniors as akin to "selling fire insurance to someone with a house on fire."
But Howard Cohen, former GOP aide for the House Commerce Committee who is a lobbyist with the Washington law firm Greenberg Traurig, responds, "It would be ludicrous for insurers not to enter this market."
Sorian and Cohen appeared at a recent healthcare forum in Washington where each was listed as a representative of the respective campaign for which he spoke.
Republicans also are charging that the Clinton plan will result in a big-government program with price controls and restricted access to some drugs.
Medicare clash. On Medicare reform, both argue that the solvency of the trust fund needs to be extended past its current expiration date in 2025. But the similarity ends there.
Unlike in 1996, when Democrats were able to savage Republicans over a GOP congressional balanced budget plan that proposed $270 billion in Medicare savings during seven years, Gore now is talking about setting aside surplus dollars to extend the solvency of the trust fund, much like Clinton has proposed for the past two years (Jan. 31, p. 6).
The Gore "lockbox" plan, in theory, takes Medicare savings out of the general budget and sets it aside for program improvements and paying down national debt. Gore supporters say the plan will prevent Medicare spending from becoming a hostage of annual budget battles.
"What you'll find is that future changes to the Medicare program will be based on the Medicare program's needs," says White House healthcare adviser Christopher Jennings, an informal adviser to the Gore campaign.
Congressional Republicans have taken steps to neutralize that pitch. The House recently passed legislation that would bar Congress from calculating surpluses in the Medicare Hospital Insurance Trust Fund as part of the overall budget surplus and would require that the money be used to pay down the debt (June 26, p.2).
Bush, meanwhile, has said he will build on the work of a bipartisan commission that proposed, but failed to approve, a Medicare restructuring plan. Under that proposal, the program would pay most, but not all, of the premiums for seniors enrolling in private plans.
That "premium support" proposal comprises legislation sponsored by Sens. John Breaux (D-La.) and Bill Frist (R-Tenn.).
In fact, Bush charges that Gore has stood in the way of reform because the administration's appointees to that bipartisan commission voted against the premium-support proposal, sealing its fate.
The difference in their vision of the future design of the Medicare program could be the wedge issue that Gore can capitalize on.
"If Al Gore were to say, `George Bush wants to provide a prescription drug benefit by forcing everybody into HMOs,' that would be pretty inflammatory," says Thomas Scully, president and chief executive officer of the Federation of American Health Systems.
"It's just a matter of time (before Gore does it)," Scully says. "They've got to have an issue a week. Sooner or later they'll land on that one."