US medical reform: now is not the time

Despite the uncertainty surrounding the outcome of the US presidential election, most commentators are certain that little improvement in the medical care system is likely. The United States has never been so wealthy.

Economists estimate that the government will run a surplus of $4.5 trillion over the next 10 years. Yet 43 million US citizens, one in six, remain without medical insurance. Neither presidential candidate has proposed universal medical suffrage. Neither has offered an idea to cut medical costs and waste. The sole difference is that Mr Bush has leant toward more privatisation and Mr Gore toward more public support. For example, both have focused on the rising costs of drugs, especially among elderly people, as the major medical issue facing the United States. Drugs account for about 5% of medical costs, and their costs are rising at about six times that of general inflation and three times that of the rest of the medical system. Because the government insurance plan for elderly people, Medicare, does not provide coverage for drugs, elderly people are burdened with costs that can run to thousands of dollars a month.

As a result, it is now common to see buses filled with elderly people crossing Canadian and Mexican borders to get drugs at 40-50% discount. Mr Bush wanted to cover most of the cost of drugs for poor elderly people; Mr Gore also wanted to do that, plus provide some discounts to all Medicare patients. Mr Bush aimed to do this through further privatisation. He proposed to dramatically shrink the monolithic government health insurance plan for elderly people and substitute it with payments directly to them so that they could shop on the open market for a health insurance plan of their choice.

Various plans would offer various drug benefits. Mr Gore favoured more government oversight of private insurers wishing to offer plans to the elderly. “Governor Bush has a plan to much more aggressively enrol people in private insurance plans,” said John Goodman, president of the National Center for Policy Analysis. “His proposal … would grant generous tax relief to people who buy their own insurance.” “The Bush approach is … too little, too late, and too hard to match with decent insurance coverage,” countered Judith Feder, dean of policy studies at Georgetown University. “They're offering a 10 foot rope to people in a 30 foot hole. The vast majority of the uninsured cannot afford to buy insurance nor … is it likely to be available to them with the tax credit he's offering. Vice President Gore, by contrast, is building on public programmes that we know from experience are the most effective way to reach the people who cannot afford health insurance.” But the election has now made these differences, slight as they are, virtually irrelevant.

Federal deadlock means neither Mr Bush nor Mr Gore would have a tight enough hold on his party to control every legislative colleague. Therefore, bold reform of medical care will be virtually impossible during the next four years. “Though it is unconscionable that the richest country in the world refuses to cover the insurance needs of all its residents, neither candidate proposes to do much about the problem anytime soon,” reported the New York Times on 24 September. “True, they have plans to spend the surplus on other purposes, some of which are worthy in their own right. But if this moment—a moment of unprecedented economic prosperity and looming budget surpluses—is the wrong one for an aggressive move toward universal health insurance, when will it be right?” Many people now look to the next presidential election, in 2004, as the key year in which medical care will again rise to become a national crisis. By that time, so they hope, the country will have tired of deadlock: more than 10 years will have passed since President Clinton's failure to overhaul the system, and the economy will probably have slipped so that the medically disposed will grow in number. In short, many expect the medical system to get worse in order for it to get better.