Democrat and our wooden-yet-slightly-wacky centrist Democrat? The substantive conflict, most pundits will tell you, has to do with health care, though exactly what is not immediately clear. Since Bradley unveiled his health proposal in September, the two have been trading technical yet not terribly enlightening jabs over how they propose to fix the world’s most expensive health care system, which happens to leave slightly less than one-fifth of the country and some one-fourth of New Yorkers without health insurance. Consider the baffling statement Bradley made at the Apollo last week:
“We’ve talked a lot about my health care proposal in this campaign. In these terms—it’s a disability. The disability under medicaid, it saves the same amount of money, it’s the same services, it’s the same benefits. The only difference is that now if you have HIV, you can qualify for insurance. And if you are in a neighborhood, you get a health—you get a community health benefit. That’s the only difference.”
Herewith the Voice hopes to make the difference between the two Democrats’ health care plans a wee bit clearer. For starters, the Bradley plan is decidedly more elaborate than Gore’s. Bradley’s massive revamp would mandate coverage for kids and give poor people tax breaks and subsidies to help pay for private insurance. Perhaps the most controversial element puts many people who are now on medicaid—the government health care program for the poor and disabled Bradley was trying to talk about at the Apollo—into the private insurance plans that currently cover government employees. The idea of doing away with medicaid has brought outraged squawks from some advocates for the poor, but Bradley promises he’ll replace the safety-net program with “something better.” By his own estimates, which have been criticized as unrealistically low, the sweeping changes would cost $65 billion a year.
Gore has a somewhat sleepier proposal—or nonproposal, according to Bradley supporters—that would increase coverage by expanding government programs, such as Medicare and the Children’s Health Insurance Program. His biggest promise is to get all children access to affordable insurance by 2005, a not terribly ambitious goal, according to most policy types.
Bradley claims he’ll extend health coverage to 95 percent of the population within his first few years in office, while the vice president’s program would “easily get to 90 percent of the population within eight years or so,” says Irwin Redlener, Gore’s national health adviser. But Kenneth Thorpe, a health economist who has analyzed both plans, figures that both proposals would have strikingly similar results, with Gore’s plan resulting in about 88 percent coverage as opposed to 89 percent for Bradley’s plan.
So the real question is not how much insurance coverage the Democratic contenders would provide (not enough, in both cases) but how they’ll do it and whether their strategies will put us on the road to universal coverage. While Bradley may have the more dramatic plan, the Gore camp has earned prudent-choice points for being the opposite: slow and respectful of the political realities that brought down the Clinton plan in 1993.
“Gore’s proposals help lay the next paving stones on the path towards universal coverage,” says Gore supporter and Manhattan assemblyman Richard N. Gottfried. Gottfried admits there’s still a lot of paving to do on the long stretch between upping the income limit for the Children’s Health Insurance Program and dropping the eligibility age for medicare from 65 to 55, as Gore promises to do. Nevertheless, argues Gottfried, who chairs the state assembly’s health committee, Bradley’s big alternative represents the wrong road entirely. “To get to meaningful universal coverage from Bradley’s plan,” says Gottfried, “we’d have to back up and start all over again.”
The reason Bradley bugs Gottfried-style health reformers—the kind that still hope for a single-payer, Canadian-style system that would insure everyone—is that he proposes handing over some $258 billion to private HMOs. “These are the same companies that are causing the number of uninsured to rise in the first place,” says Mark Hannay, director of the Metro New York Health Care For All campaign. “Most advocates think that’s continuing to feed the beast.” Because that “beast” can eat up as much as 30 percent of the health dollar in overhead costs, as opposed to somewhere around 4 percent for medicare and other public programs, Bradley critics fear his proposed subsidies (or vouchers, as they like to call them) would buy profits instead of decent health benefits.
Bradley supporters respond that those public programs that Gore would build on are already being farmed out to private companies. Indeed, HMOs are already serving—and sometimes, when they’re not profitable enough, backing out of serving—medicare recipients. And, in New York, most medicaid recipients already have to sign up with HMOs. That, says Bradley aide Margy Heldring, is just one of the problems with the lumbering program for the poor that’s become central in the Gore-Bradley battle. “Medicaid is second-class health care. It has excellent benefits on paper, but often there are few providers to provide them,” says Heldring, who notes that only one out of 17 dentists in New York State accepts medicaid.
Many health advocates agree that there would be an upside to mixing the poor in with the rest of American patients. “It’s a very good idea to have everyone in the same system,” says Susan Dooha, director of health policy for Gay Men’s Health Crisis. But even so, Dooha worries that by getting rid of medicaid, which is strictly regulated and now covers around 100,000 New Yorkers with HIV, “we’d be trading in a known quantity for a pig in a poke.”
Alas, we may not have a chance to learn much more about that pig. As the primaries wear on and Bradley’s chances fade, the specifics of his plan seem less and less the point. Just a handful of years after the Clintons’ reform effort tanked, coming up with a health care proposal at all may be Bradley’s contribution. “At least he put something on the table,” says Howard Berliner, a professor of health policy at the New School and policy consultant to 1199, the city’s largest health care workers union, which has endorsed Gore. Berliner thinks even the staggering expense and confounding details of Bradley’s plan could help wake people up to the issue. “He’s saying, ‘Hey folks, it’s worth it, it’s health care.’ ”
Kids: Mandatory coverage. Would provide subsidies up to 300 percent of poverty level.
Medicaid: (now for poor and some disabled): Would provide subsidies for people now on medicaid to buy private insurance. Medicaid still in place for long-term care.
Medicare: (now for those over 65 and some disabled): Would provide optional prescription drug benefit.
HMO reform: Supports right to sue HMO if harmed.
Kids: Would raise cutoff for Children’s Health Insurance Program from 200 to 250 percent of poverty level.
Medicaid: Believes incentives to enroll children in program should be greater.
Medicare: Would allow people 55 and over to buy in. Offers prescription drug benefit capped at $1000.
HMO reform: Supports the right to sue.