· should patients be allowed to sue HMOs? · should there be universal coverage for the uninsured? · what should be the future direction of Medicare? · should tobacco be regulated as an addictive drug?

Not much has changed since the early nineties, when the Clintons promised to make universal health coverage the top administration priority. Those plans were roundly rejected by Congress and today, the crisis in the health care system remains. Though some 100 million people are covered by health insurance offered by HMOs, Americans voice dissatisfaction with the country's health care delivery system saying that the trend towards HMOs has meant poorer quality of care, though at a lesser cost.

The United States spends more on health care than any other nation, but the large number of uninsured has meant the country rates poorly in terms of access to quality health care. An estimated 44.3 million Americans - one in six - have no health insurance. This includes eleven million children. But neither party espouses universal health coverage, which was first unsuccessfully floated by President Harry Truman back in 1945. Equally contentious is the future of Medicare, founded in the 1960s to provide universal health care to the elderly. Medicare is especially strained from catering to a rapidly growing aging population: while 40 million Americans depend on Medicare today, the number is likely to be 80 million by 2035.

Al Gore claims to have a greater commitment to the issue of making quality healthcare available to all Americans. As Senator he has co-sponsored legislation on health issues and as Vice President been outspoken about a Patients Bill of Rights, access to quality healthcare for women and children and mental health. He has pledged to make HMOs more accountable and improve Medicare coverage. However, the Clinton administration, which promised to make the healthcare overhaul a major priority, failed to convince Congress of its healthcare plan and effectively dropped the issue. This inaction has been seized on by Bush and other critics, who point out that 8 million more Americans have in fact lost insurance coverage under this administration. However, Texas under Governor Bush has had one of the poorest public health records in the country.

Bush has also made Medicare reform a priority in his campaign. "Medicare is an enduring commitment of our country, but it must be modernized for our times," he says.

Should patients be allowed to sue HMOs?

Gore is a strong proponent of a patients bill of rights for all Americans, which he says should allow patients to appeal HMO's medical decisions through an independent process, and ensure access to emergency rooms, specialists and clinical trials. " It's time to take the medical decisions away from the HMOs and insurance companies, and give them back to the doctors, the nurses and the health care professionals," he has said. His rhetoric has been criticized by observers who feel that HMOs have cut costs by slashing unnecessary procedures and waste. They point out that countries with universal health care would not have covered most of those procedures and that most people claim they are happy with their own HMO. "It is fruitless and unfair to blame all the ills of our health care system on the HMOs, which are based on an attempt to maximize the population's health within a pre-set budget," observed Jonathan Weiner, professor at the Johns Hopkins School of Public Health, in July, 2000. "HMOs are part of the cure for what ails us, not part of the disease."

Bush proposes allowing patients to appeal denials of care to an independent review panel and, in some cases, to sue their HMO. In general, he believes in giving states more flexibility in enforcing and regulating patients rights.

Should there be universal coverage for the uninsured?

Gore does not believe in guaranteeing universal healthcare access, except for children. He estimates that all children can be insured by 2004 by expanding the federal Children's Health Insurance Project and Medicaid. He also proposes a 25 percent tax credit for people who buy health insurance because they aren't covered at work. He is opposed to the medical savings accounts proposed by Mr Bush, which he thinks will benefit wealthy Americans. His critics say he does not go far enough on the issue, Boston Globe columnist Ellen Goodman commented sarcastically: "Health care is reduced to a fight about a patient's bill of rights that doesn't include the right to health care."

Bush does not believe in universal health care, but proposes making insurance more affordable by giving low income families a tax credit of up to $2,000 to buy their own insurance. He also says he will spend $3.6 billion to increase the number of community health centers serving poor areas and allow for tax free medical savings accounts for individuals and families to buy insurance. He supports allowing small businesses, which account for 60 percent of the uninsured, to buy lower cost insurance through trade associations.

What should be the future direction of Medicare?

Gore proposes putting Medicare in a "lock box," so that its surpluses, which could be as high as $400 billion over the next decade, can only be used to shore up the program. About one-third of Medicare beneficiaries have no prescription-drug coverage at all and many of the rest pay high drug prices despite their coverage. Gore has promised to provide free drug coverage for 13 million low-income recipients, while those with higher incomes would pay part of the cost of their drugs. Critics point out that this will make the government too big a force in the setting of drug prices.

Bush has proposed a comprehensive Medicare overhaul, named MediCARES, which he says will modernize Medicare by giving seniors the choice to select benefits they need most: annual physicals, hearing, eye, and dental care, and prescription drug coverage. While this program is being phased in, he would provide states with $48 billion to immediately help seniors with prescription drug coverage, picking up all or most of the cost for seniors at 175 percent of the federal poverty level. Long term care like nursing home stays not covered by Medicare, will be fully deducted annually from taxes. Persons with elderly dependents would be allowed to claim an exemption of about $2,750 annually. Bush also proposes charging wealthy Medicare recipients more for coverage.

Should tobacco be regulated as an addictive drug?

Gore believes that Congress should give the Food and Drug Administration the power to regulate nicotine as an addictive drug.

Bush does not take a position on whether the Food and Drug Administration should regulate tobacco as an addictive drug. However, he proposes that Congress and state legislatures should pass laws further restricting access to tobacco by minors.

FRONTLINE's Dr. Solomon's Dilemma examines doctors' dual responsibilities to their patients and their bottom line in the age of HMOs.

http://www.patientadvocacy.org/
Center for Patient Advocacy

http://www.nytimes.com/library/politics/camp/whouse/policy-health.html
New York Times Healthcare issue guide (requires free registration)

http://www.theatlantic.com/issues/2000/10/miller.htm
"Healthcare: A bolt of civic hope" (The Atlantic Monthly)