Before he helps me translate the candidates' sound-bite-speak, I ask Professor Schlesinger what his general politics are. "You're getting a relatively unbiased perspective," he says. He calls himself a conventional Democrat "in terms of favoring a role for government." But, having spent a long time working with both Republicans and Democrats in various consulting roles, he has "a pretty good feel for what's good about their respective positions."
Yale Herald: What are the pressing issues in the country's health care system?
Professor Schlesinger: We've got about 45 million people who don't have insurance. For some of
them, it's transitory, they're between jobs, but about three-quarters are uninsured for two years
or more. That's a pretty substantial chunk of the population.
YH: Has there been an increase in the uninsured over the years?
MS: Since the early 1980's, the number of uninsured goes up by one million every year.
YH: Why has this happened?
MS: Health care has gotten more expensive over time. Most people get insurance through work, but
now, employers, particularly small employers, often think they can't afford it anymore.
YH: So, it's mostly because workplaces have stopped offering insurance.
MS: There's one additional trend that kicked in about '94, which is welfare reform. All of a
sudden, you couldn't be on welfare for more than two years of your life. We kick you off
afterwards. Now, a very important source of health insurance for people without much income was a
government program called Medicaid. And, prior to welfare reform, you got Medicaid primarily by
being on these cash assistance welfare programs. After welfare reform - this was very bipartisan,
both Republicans and Democrats - look we want to take people off cash assistance, we don't want to
take people off Medicaid. Because everyone agreed it was important to have health insurance even
if you weren't getting this cash support. So they built into laws these very careful provisions
to try to let people know that their Medicaid eligibility would continue even if their cash
assistance stopped. And to essentially penalize states who didn't do that. In spite of all those
protections that were built into the law...what happened after welfare reform? A lot more people
stopped getting cash assistance, and all of a sudden Medicaid rolls just dropped.
YH: So is it the state who are doing this, or the people who just don't know?
MS: Well, it's a combination of those things. The states probably aren't doing as good a job
administering a program and doing outreach and publicizing it, that's part of the reason that
people don't know. It's part of the fact that, to get your cash assistance you used to have to go
to these welfare offices. You sign up, and when you sign up they say, "oh by the way, you're
eligible for Medicaid, so sign up for that as well." Now, when people don't go in to get cash
assistance, they just don't have any no contact with the system. Now, one of the ways that people
tried to prevent dropping off Medicaid, they built in a new provision that would allow people who
go to the doctor's office to get signed up for Medicaid at the doctor's office. Without having to
go into the welfare office. But if you don't know you're on Medicaid, if you don't think you're
covered, you don't go to the doctor! Unless you have some contact with the system, you're not
gonna be signed up. And if you're not signed up, you're not gonna have any contact with the
system.
YH: What are Gore and Bush's positions on this problem?
MS: It's become a big political hot potato. Each want to blame the other. Bush will say, listen
Al Gore, this was your administration that enacted welfare reform. You failed to effectively
enforce these provisions which would keep people on Medicaid. Gore's position is, George Bush,
you were the governor of Texas, Texas has the worst record in any state of administering Medicaid!
You have the most poor kids who don't have health insurance. You're the problem.
YH: Are both claims true?
MS: Yes. They both have plenty of ammunition to blame the other, because Medicaid is a joint
federal-state program. Admittedly, the vice president doesn't have much influence on Medicaid
policy, so blaming Gore is a little weak. On the other hand, it turns out that in Texas, the
governor is a pretty weak governor, so blaming Bush is also a little weak
YH: Besides Medicaid, Medicare is another huge issue in the election.
MS: Medicare is important because, as people get older, health care becomes a major ongoing part
of life. You go to the doctor more often, it becomes a much more salient issue. Also, the
elderly are the single age group most likely to vote.
YH: What are all the concerns about HMO's?
MS: Medicare started as one uniform federal program for all the elderly and disabled, with
everyone in the country having a benefit package. But beginning in the early 1980's, Medicare
allowed beneficiaries to sign up for HMO's. This is just like an insurance plan, but it has its
own set of doctors and services. With Medicare, you can go to any doctor in the country, any
hospital anywhere in the country. If instead you join one of these HMO's, you have to go only to
the particular network of physicians or hospitals that are connected with the plan.
YH: Why would anybody join HMO's over Medicare?
MS: Well, in principle these narrower networks of plans can cut a better deal. They can find
services at a lower cost, and roll the additional savings into additional benefits, into things
that Medicare doesn't normally cover. Like prescription drugs.
YH: You were saying this is only in principle.
MS: Well, the problem is that if an HMO's services are unstable. If they have a really bad year,
they might drop out of Medicare entirely. So an elderly person totters over to the HMO and signs
up for a particular physician. Next year he discovers that their HMO is pulling out of the
Medicare market. Now all of a sudden he has to change his doctor.
YH: What are Gore and Bush's stances on HMO's?
MS: George W. Bush says isn't it great, people get to choose what plan they want to go into, they
don't have to stick with the government plan." Al Gore says, sure they get to choose their plan
but their plan drops them. That's just a bunch of insecurity. They can get more benefits, but
they can also get mistreated. Depending on how you view this history, you can see this Medicare
HMO participation as being an improvement over government, or a great foible of the private
market.
YH: What's all the talk about prescription drugs?
MS: When Medicare was created in 1965, prescription drugs were not typically covered by private
insurance or Medicare. But over the years, with more pharmacological improvements, there are a
lot more drugs out there now that are life-saving. And very expensive. The elderly are spending
more and more of their income on these drugs which weren't paid for by Medicare. In many cases,
if you were a low income elder, you just weren't buying drugs, because they couldn't afford them.
People agreed it was not a very good system, and there's pressure to incorporate some kind of
pharmaceutical coverage into Medicare, especially for low income people.
YH: What's Gore's proposal for dealing with prescription drugs?
MS: People in Gore's campaign say that we ought to add it to the conventional Medicare program.
Low income people might get it free; if you have higher income, you would have to pay a little for
it. But it would be just one insurance package for everyone, just like Medicare. It would
essentially be bulk purchasing by the government, which, from the Gore perspective, is a great
deal. After all, if you're an insurance plan that enrolls thirty million elder, five million
disabled people, you could cut a pretty good deal with drug companies. Everyone gets treated the
same, prices get kept low because you're a big central purchaser.
YH: George W. Bush says...?
MS: He says, gosh no. This is big government. What Bush would prefer to do is to have the federal
government subsidize people purchasing private insurance, for people to have choices among
private plans, as opposed to just going into one plan.
YH: It's a conventional Republican-Democrat disagreement.
MS: Exactly. They're trying to confuse you, but it's really a split between market arrangements
and government arrangements.
YH: There was some mention of that HMO "cherry-picks" their senior citizens, leaving Medicare with
the sicker patients.
MS: You're paying the HMO a fixed amount of money per elder, so they do better if they have
healthy ones. There is some evidence to suggest that they do select out the healthy ones. The
big concern on the Democratic side is that, if you left all the healthy elders go to HMO's and all
the sick ones are stuck in Medicare, that makes the traditional program more and more expensive,
everyone says, "big government, it's really inefficient, this is bad" and the program loses its
political support. From the Bush side, they don't care. They'd be just as happy if government
program eroded.
YH: Gore talks a lot about universal health plans.
MS: Gore is very clear that he wants to get everyone covered. He's not sure how to get there,
but he's trying to get there. And there are tremendous debates about whether the way Gore wants
to get us there is sensible way or not. But what it comes down to is whether this is a goal that
we should embrace and struggle towards. Because it would be a struggle one way or another.
YH: How much are these promises worth? Do these policies they talk about have a change of going
into effect?
MS: What you can count on is that they'll try to do it. Clinton was elected in '92 and the
promise of health care reform. And he tried. He didn't get it through. There are a lot of
things that are going to effect their ability to actually implement these things. Because we're
in an era of pretty big government surpluses the conditions are right for us to be able to do
these things. Most of the things that are proposed are plausible. They're not implausible
promises.
YH: On his website, Bush accuses Gore of " trying to force senior citizens into government HMO's?"
What does that mean?
MS: There's really no such thing as government HMO's. HMO's are all private entities. But he
knows that people hate HMO's. If he says government HMO's, two things people hate together, it's
a good way of smearing the Gore plan. It's true that Gore is advocating a government plan, but
it's kind of a nonsensical term.
YH: And when Gore, on his website, accuses Bush plan of " forcing low income elderly people to go
to welfare offices"?
MS: Bush's plan is not very well thought out. He's not really a health person. He has health
advisors, but he kind of cobbled this plan together very quickly. Part of this program involves
administering the program through the states. Kind of like Medicaid. So that's why they're
saying they're gonna force them to go to welfare offices, because it's kind of Medicaid-like in
its structure. Now, whether that's true or not-I think Bush hasn't even thought about how to
administer his program. So it's an unfair criticism, but it's true that it's moving away from
federal government uniform national program that Medicare is.
YH: Both are just smearing the other with inaccurate terms.
MS: Yup. People need to understand the overlay of deliberate confusion that the candidates
produce in this issue.
YH: Why does this happen?
MS: One thing is that health care, conventionally, ranks as only third or fourth most important
issue in terms of influencing an election. The candidates know that. They know it might swing
5-10 percent of the vote, but no matter what their position is, it's not gonna get them elected or
not elected. They also know that most people don't understand the health care system, it's too
complicated, and they don't have the time to pay a lot of attention to it. So, how do they
communicate their message? Most people are going to remember just these little sound bite nuggets.
And so each side is searching for very brief descriptors, which people will hold in their heads.
YH: Like "government-run HMO's."
MS: Right, or like "forcing seniors into welfare offices." They're looking for simplistic terms,
and there's some truth to each of them. Trying to send the message concisely is a good thing, but
each feels compelled to spin it in a way that smear the other side. That's what you have to try to
get people to step past, saying, look, there is a meaningful differences here.
YH: What's your opinion about it?
MS: I think it's one thing to say let people make choices when they're twenty or twenty-five.
It's another thing to say let people make choice about their retirement income and their
retirement health care. Because it's not a time of life when people want to take a lot of
chances. It's a time of life when people want to have some security. I can see perfectly
acceptable arguments for injecting the market in lots of realms of life, you don't inject the
market in a realm of life where security is the paramount concern. That seems to me what's
strikingly wrong about the Bush both social security and Medicare proposals. It's not that
they're wrong fundamentally, but that there's a mismatch to what people care about at that age.