A Better Prescription For What Ails Us

By Joe Klein

Over the past few years, President George W. Bush has demonstrated a staunch unwillingness to compromise with the Democrats--except when it comes to their worst ideas. He caved on school vouchers, even though his limited plan might have provided a needed jolt of creative competition in the poorest neighborhoods. And last week he indulged the Democrats--along with the powerful AARP and other selfish senior lobbyists--on prescription drugs for the elderly.

The Senate Finance Committee, once one of the few responsible congressional outposts, opened the bidding with a $400 billion proposal over 10 years. This just weeks after Congress passed a $350 billion tax cut that may well cost $800 billion to $1 trillion when its accounting tricks are untangled. And this in a year when a $400 billion federal budget deficit is predicted, along with many more deficit zeros in the years to come.

The Senate prescription-drug plan is yet another slovenly bit of business. Here's how it works: You pay a $35-a-month premium. You have a $275 deductible. The government pays 50% of your drug bills up to $4,500. Then it stops. Then it starts again if you pay more than $5,800 a year. In other words, a senseless stop-and-go ladder system that applies to all Medicare recipients regardless of income. And its bottom line? You have to spend $1,200 in premiums and deductibles and co-pays before the government spends $1,201. About 35% of seniors would pay in more than they get back. Another curious feature: the program doesn't start until 2006. So why the rush to pass it now? Could it be the 2004 election? The Democrats have been boggled by Bush once again. They will have the sour satisfaction of getting their wish--prescription drugs for the elderly--while granting the President a domestic-policy triumph to equal his airborne landing on the U.S.S. Abraham Lincoln.

Until last week the Republicans were more responsible than the Democrats on the prescription-drug issue. In 2000 Bush favored a plan that would help only the seniors who needed it most--the poorest, those who had to choose between food (or bankruptcy) and medicine. More recently the Republicans hoped to use a prescription-drug benefit as an inducement to seniors who agreed to leave Medicare's archaic, expensive fee-for-service system and join a managed-care group. The Democrats demagogued this as "herding the elderly into HMOs." Actually, the Republicans were hoping to impose some structure on a runaway program whose costs will explode when the baby boomers retire--and they were proposing only that the elderly receive the same sort of (managed) care that most nonelderly Americans do. Those were the principles Bush abandoned last week. And the Republicans are complicit in another accounting fraud. The obvious defects in the Senate bill will be fixed sometime before 2006--you can bet no seniors will ever pay more into the prescription-drug plan than they take out--but not this year. The ultimate cost will be--What, $700 billion? $1 trillion?

Senior citizens are compulsive voters. Health is their issue. And so debate on a crucial domestic-policy question is hopelessly distorted. We talk too much about age and too little about need. The most important health-care question is rarely asked: Given the limited resources, what should be our spending priorities? I suspect that the correct answer isn't subsidizing prescription drugs for all senior citizens regardless of income. A better answer might be subsidizing the worst-case health-care situations regardless of a patient's age. Obviously this would still mean prescription drugs for the elderly poor. But what would it mean for the rest of us? Senator John Kerry of Massachusetts proposed an elegant first step in his campaign health-care plan; it may be the first significant new idea of this political season.

Kerry wants the government to help pay for catastrophic health-insurance claims (those in excess of $50,000 a person). These represent only 0.4% of all claims but 20% of all health-insurance payouts. Ken Thorpe, a health-policy expert at Emory University, says such a plan would allow insurers to reduce current health-care premiums 10% across the board. Kerry would also provide tax subsidies for those who don't have health insurance, as would several other Democratic presidential candidates. He would pay for the expanded coverage by rescinding the upper-bracket Bush tax cuts, as would the others. But his catastrophic safety net is unique and suggests a universal principle: government should involve itself in only the most serious health-care situations for the most needy people. Unfortunately, neither party seems in much of a mood for a careful discussion of first principles, and a health-care system that is a national disgrace seems in danger of becoming a national disaster.