Major differences separate the leading presidential candidates on the subject of the role of government in health care, although the issue has not been central to the campaign.
The essential difference is George Bush’s preference for a relatively passive role by government, and strong opposition to mandating what employers should do to protect their employes, as opposed to Michael Dukakis’ commitment to a government role requiring basic health protection for all workers and extending the universal health-care system he developed as governor of Massachusetts into a national program.
In their most direct discussion of the issue, during the first presidential debate, Bush emphasized his opposition to mandating health care, while suggesting that the government role be limited to extending Medicaid, the poverty health-care program, to additional low-income persons. Dukakis, on that occasion, reaffirmed his commitment to require all employers to do what most employers already do and provide basic health insurance to their workers.
Bush’s proposal to allow additional persons to buy into Medicaid has been introduced in legislative form in Congress by Sen. John H. Chafee (R-R.I.) as the Med America Act of 1987. Under its provisions, states would be given the option of offering Medicaid to all whose income is at or below the federal poverty level, and to allow the working poor and those excluded from other health insurance to buy Medicaid protection. Premiums for the working poor would be capped at 3% of their family-adjusted gross income.
The principal weakness of the Chafee plan is that Medicaid, called Medi-Cal in California, has proved to be a disappointing program. Each state has been allowed to set its own standards because the states share the cost with the federal government, and even in the most generous states, such as California, fees to health-care providers are so limited that it is difficult for Medicaid patients to find doctors and dentists to care for them.
Dukakis’ proposals for mandated health insurance parallel legislation sponsored by Sen. Edward Kennedy (D-Mass.), which would require most employers to provide basic health insurance. Like the minimum wage, this has stirred controversy, supporters arguing that it is the minimum the nation must do, while others argue that it would hurt the economy by bankrupting small and marginal business operations. Dukakis also has affirmed confidence in the Massachusetts plan that assures global health coverage through a combination of mandated health-insurance protection and a payroll tax to finance a state insurance pool for companies that do not provide insurance. But its real cost will not be known until it is fully implemented in 1991. And some critics have argued that it is not adaptable to all states because most states do not enjoy the vibrant economy and low unemployment of Massachusetts.
We are astonished that health care has not attracted more discussion, for there is a crisis. The crisis is evident in the fact that as many as 38 million Americans, most of them employed or the dependents of workers, are without health insurance, and that the nation’s infant-mortality rate ranks among the highest of all industrialized nations even though the United States spends more on health care than other nations.
There is broad agreement in Congress that health care will be high on the agenda in Washington in the next four years, regardless of who is President. There is the obvious issue of access when 38 million have no health insurance. And there is the increasingly difficult problem of long-term care in an aging population as thousands of elderly Americans are forced each year to impoverish themselves to become eligible for Medicaid coverage of nursing-home care. The landmark legislation of the last session, extending Medicare benefits for hospitalized elderly, did not address either of these critical problems.