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Drugs are extraordinarily expensive,
but they have been for a long time. During my 20 years of practice, I
was often faced with patients who simply could not afford the drug
therapy I thought they needed in order to maintain their health. Many
of these were elderly, but frankly, many were not. I and many other
doctors have long felt that something needed to be done to help those
who could not buy needed medications. (Many of these unfortunates, by
the way, were workers who were subsidizing - through their taxes - not
only Medicare benefits for the elderly, but also "private" insurance
benefits for those lucky enough to receive health insurance through
their employers.) So the inability to pay for prescription drugs is
not a new problem that suddenly needs to be addressed, on an emergency
basis, in the year 2000. The problem has been there for decades.
The uproar over the Medicare drug
benefit, then, does not represent any new realities. It's just that,
for whatever reason, insisting on a Medicare drug benefit has become
the proxy, in this election year, for demonstrating one's concern for
the growing health care crisis.
Actually addressing that health care
crisis is, of course, out of the question. The Clintons were brave
enough to try during their first two years in office, but made such a
botch of the job that it cost them the House and Senate, and knocked
the president's liberal agenda completely off track for the remainder
of his terms. (His major successes - such as balancing the budget -
were made by usurping traditionally Republican issues, much to the
frustration of the GOP.) No political party will ever again directly
take on the health care crisis until forced to do so by unavoidable
circumstances.
The Patient's Bill of Rights appeared
to be, for a long time, this year's emblem of concern for the health
care crisis. But that bill is bogged down, and neither party shows
much interest in moving it very far - or even talking about it much -
before the election.
Enter the Medicare drug benefit. The
price of drugs - and the vilification of the drug industry that
promotes those high prices - has been a growing theme in the media, in
several state legislatures, and more recently, in the U.S. Congress,
all year. (Those of you who have been following these commentaries -
especially the series of commentaries called
Philip Morrising the Drug Companies - will recognize the theme.)
The theme of high drug prices has reached such a pitch that, when
various Democrats proposed offering prescription drug coverage to
Medicare patients a few months ago, the notion struck a chord. The
AARP, the media, and even several Republicans, jumped on the idea. In
no time, the Medicare drug benefit had become the means of
demonstrating concern over the state of our health care system.
What
the Gekkonians are up to
Providing prescription drug coverage
for Medicare patients - no matter how it is done - is a bitter pill
for Gekkonians to swallow. Whatever form it may take, it amounts to a
huge, federally-guaranteed new entitlement - an outcome that any
Gekkonian worth his or her salt would abhor. Furthermore, as I
pointed out in a
prior commentary, any
federal drug guarantee for the elderly creates an immediate problem
for two major Gekkonian constituencies - health plans and
pharmaceutical companies. Managed care plans, already in grave
financial straits, fear they’d be left holding the bill for any
federally-mandated drug coverage. And drug companies fear they’ll be
faced with federal price controls. Both of these fears are
well-founded.
Yet, the Gekkonians
found themselves about to be outflanked by the Clintonians on an issue
that seemed to carry huge political weight, and were thus forced to
act despite their constitutional proclivities.
They chose a method that was Machiavellian on one hand, but on
the other, made a major policy concession they will never, ever be
able to retract.
The proposed
Republican legislation (that narrowly passed the House on June 28),
would provide federal subsidies for private insurance companies, to
entice those companies to create a new form of insurance that covered
only prescription drug costs. Despite the steadfast assertion of
major health insurance companies that they do not intend to sell such
insurance, Republicans propose to set $40 billion aside to subsidize
it. In the “unlikely event” that private drug insurance would not
change their minds, the government would become the insurer of last
resort under the G.O.P. plan.
In addition, the
Republican plan calls for creation of a new federal agency (the
Medicare Oversight and Management Administration) to oversee drug
benefits and Medicare HMOs. This new agency, unlike present Medicare
administration, would be biased in favor of free-market solutions to
the problems of the Medicare population, and would (so they say)
actively avoid the complex and difficult regulations so favored by
current administrators.
So what the
Gekkonians have done is to fashion a drug plan that appears
to be based in the free-enterprise, for-profit world Gekkonians love.
But in reality, since the insurance companies are
too smart to actually sell a drug insurance product, private
prescription drug insurance will be difficult to find. Thus, even the
Gekkonian plan leaves the government "insurer of last resort" in
charge. The proposed new federal agency - aimed at encouraging free
enterprise solutions to Medicare problems - is actually, one suspects,
a poison pill aimed at guaranteeing a presidential veto.
A veto would allow
the Gekkonians to claim that they were the first to come up
with a viable Medicare drug plan, and that the Clinton-Gore
administration vetoed it out of spite. And what you're left with,
elderly citizenry, thanks to Clinton-Gore, is squat.
What the
Clintonians are up to
The Clintonians
thought they had this issue sewn up. The groundwork for whipping up
public sentiment in favor of a new entitlement for Medicare patients
had been carefully laid. And when the proposal was made (not, to be
sure, as something to be accomplished this year - but instead as a
campaign issue, as a promise, as a reason for voting Clintonians into
office), they fully expected to see the Quayleian,
deer-in-the-headlights reaction from their Gekkonian rivals. It was
meant to be a sure winner. A trump card.
This is why the
Clintonians have reacted so violently against the GOP response.
When one thinks about
it, now that the Gekkonians have embraced the notion of a Medicare
drug benefit, all that's left to fight over is how much to spend, and
how to administer it. The chief philosophical obstacle has been
breached. If the Clintonians' chief concern was actually to provide a
drug benefit, they should be celebrating.
The Clintonians'
violent reaction to the Republican legislation (the 10 hours of
acrimonious debate, storming out of the House chamber en masse - a la
the impeachment debates, promises to veto the GOP plan for reasons of
terminal insufficiency) is a dead giveaway. Their reaction clearly
reveals that their proposal for a Medicare drug benefit was primarily
a political maneuver, and not a deeply held conviction.
The Clintonians are
now left in the unenviable position of having to convince their
elderly constituents - whose appetites are now fully whetted for
prescription drug relief this year, and not in some distant
future - that the GOP plan is so awful that no drug plan is better
than the GOP plan. The prospect of actually having to veto a new drug
entitlement for the elderly has got to make the Clintonians sweat.
The game, of course,
isn't over for the Clintonians. They have shown a remarkable
capability to sway public opinion by couching political issues in
their own terms, and they are certainly capable of doing the same
thing here. But their real hope is that the Republicans in the Senate
will block this legislation.
Senate Republicans
have, so far, been remarkably silent on the issue. If they see the
drug benefit more in philosophical terms than in political terms, they
are likely to stop the legislation in its tracks. But the prospect of
seeing the Clintonians hoisted on their own petard may be too much
even for them.
And for once, the
Clintonians have lost the initiative on a health care issue. For now,
they can only react.
July, 2003
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