JIM LEHRER: Now, health policy advisers to both campaigns, and two very interested outsiders. Judy Feder of the Gore campaign is dean of policy studies at Georgetown University. She served as a senior health care adviser in the Clinton administration. Gail Wilensky of the Bush campaign is chairwoman of the federal Medicare Payment Advisory Commission, which reports to Congress. She served in the Bush White House. The outsiders are Robert Reischauer, president of the Urban Institute, and a former director of the Congressional Budget Office; and Robert Moffit, director of domestic policy studies at the Heritage Foundation; he served as a senior official at the Health and Human Services Department during the Reagan administration. Ms. Wilensky, why is the Bush plan superior to the Gore plan?
GAIL WILENSKY: Because the Bush plan attempts to modernize Medicare as a program, representing that prescription drugs is a problem for many seniors, but it's not the only problem. We need to make sure that the plan is ready for seniors and the baby boomers as they begin to retire. Now, what is being proposed is not to push people into HMO's, but rather to make sure that all plans, including traditional Medicare, offer prescription drugs as a high option benefit, and that those who need the financial help, who are low-income, they get the help, and that people who have a stop-loss provision, that have high expenditures, that they will not be burdened, and, of course, a second piece, which is recognizing that we need to help seniors now, that we need to be able to provide some assistance for people who either because they're very low income or because they have very high expenditures need help right now. And so it's a two-piece program to modernize Medicare, to make sure that it is there for the baby boomers, to help people get prescription drugs, to help those who are very low income or who have very high expenditures, but to start immediately to make sure that people don't find themselves choosing between prescription drugs and food.
JIM LEHRER: Ms. Wilensky, is it fair to say that the major difference between the Bush plan, on prescription drugs solely, the major difference is that the Bush plan goes through private health plans rather than through Medicare itself?
GAIL WILENSKY: Well, that's only for those who do not want to stay in traditional Medicare. In the discussion of the program, it sounded as though people would have to leave traditional Medicare in order to receive outpatient prescription drugs. That's just not true. The standard Medicare program would also have to offer as a high option prescription drugs so that people who want to have prescription drugs that way would be able to, in fact, purchase their prescription drugs through traditional Medicare, not be pushed into networks or other claims if they don't want to go there.
JIM LEHRER: Ms. Feder, how do you see the major differences from the Gore perspective?
JUDY FEDER: Vice President Gore believes that all seniors should receive immediate protection for prescription drug costs. He would therefore make a prescription drug benefit an intrinsic part of the current Medicare program for all seniors, not just for low income program and as part of the fundamental Medicare benefit not to be sought through private plans. I think it's important...
JIM LEHRER: So that is a major difference from your perspective?
JUDY FEDER: Although I understand what Gail is clarifying, and I appreciate the clarification, because it's difficult to really get all of what the Bush administration is thinking from the materials we've seen so far, because there are... they are proposing two parts. They have what is being called an immediate part, which is only a low-income benefit, to be supported through grants to the states. That raises a lot of questions and only reaches up to an income of $14,000 or $15,000 for an individual or $19,000 or $20,000 for a couple. So it leaves a widow with $20,000 in income, a couple, that would not be a widow, that would be a couple with $20,000 in income, unprotected. So there...
GAIL WILENSKY: Unless they had other expenditures.
JIM LEHRER: Hold on. Let her finish - one second. We'll get right back to you.
JUDY FEDER: There's the low-income benefit that Dave described as immediate. Then the focus of much of your description has been what's been put forward as part of an overhaul of Medicare, which is again the details are unclear, and there's talk of a White House task force to develop those details. But that is the focus on the private plans, which are a far greater extent than would be true in the Gore plan.
JIM LEHRER: Let me ask some very specific questions of each of you. First, Ms. Wilensky, when you look at the Bush plan and the Gore plan, what's the difference in terms of the number of seniors, in general terms, who would be eligible for prescription drug health under the two plans?
GAIL WILENSKY: 100 percent under both plans as I see it.
JIM LEHRER: Do you agree?
JUDY FEDER: No.
JIM LEHRER: No?
JUDY FEDER: The reason I don't agree is that in the immediate term in the Bush plan, only low-income people would be eligible for a benefit, and that's an uncertain benefit, depending on state action, whereas in the Gore plan, people, all seniors would receive a benefit through the Medicare program.
GAIL WILENSKY: Well, let me just clarify something. The Bush plan, the major focus is reforming all of Medicare, modernizing Medicare, but recognizing that even to have implementation in 2003 and full operation in 2004 gives us a period for the next year or two where people are exposed. That's the reason that we have this immediate, not just low-income, but low-income and people who have catastrophic expenditures, anyone who is facing $6,000 of expenditures. As soon as the Medicare modernization program starts being implemented in 2003 and fully operational in 2004, all seniors - all seniors are eligible to receive the subsidy for prescription drugs. This is not a limited program.
JIM LEHRER: Let me bring in on this particular issue Mr. Reischauer and Mr. Moffit. Mr. Moffit, do you see the two programs going in the same place, where eventually there will be prescription drug coverage for every senior no matter...
ROBERT MOFFIT: I don't think there's any question about it. Both plans are looking at fully covering low-income seniors. Both plans are talking about subsidies, sliding scale subsidies for other seniors above the poverty level. Both plans are going to spend more money. Mr. Gore's got a plan to spend $253 billion. Bush's going to spend $158 billion. So we're talking about Medicare reform in terms of more money, taking care of low-income seniors, and also establishing a sliding scale coverage. There are profound differences, however, in the way in which these benefits are designed. There are also profound differences in the way in which they're financed and delivered.
JIM LEHRER: We'll get to those in a minute. But in terms of who is eligible, who would be covered? How do you read this?
ROBERT MOFFIT: My reading is Bush is proposing in effect universal access for prescription drug coverage.
JIM LEHRER: Do you see the same thing Mr. Reischauer?
ROBERT REISCHAUER: I see the same thing if I look out beyond four years, but the immediate plan that was presented by Bush was for the next four years. That's where the detail, and that's to give states subsidies so they can beef up or create programs for their low-income populations. And this would be a welfare program. There's no two ways about it. And one can ask, do we want Medicare to be social insurance or welfare; do we want to leave uncovered 48 percent of those who lack prescription drug coverage now as this plan would? I commend...
JIM LEHRER: Where do you get that figure?
ROBERT REISCHAUER: Of the folks who are on Medicare who lack prescription drugs, 48 percent of them have incomes higher than the cutoff in the state plans that Bush is proposing, but he's saying, "you know, look, we can do something immediately, let's move fast." My question about that would be, can we really move fast? It will take the states two, three, four years to set up these programs and work through all the kinks. I don't see this as something that's easy to do either at the national level or at the state level.
JIM LEHRER: Ms. Wilensky, you agree?
GAIL WILENSKY: The reason we're proposing it is we think we can move it fast. Twenty three states have either operational programs or programs that have already passed legislation. We think that gives a way to try to get money out to seniors quickly. One of the concerns that we have is that either to modernize Medicare or in fact even to put in place a program like Vice President Gore has will take some time. We want the try to help seniors immediately, because so many states have these assistance programs, we think we can hit that very quickly.
JIM LEHRER: Ms. Feder, you've been shaking your head here.
JUDY FEDER: Well, 23 of states do have some kind of state program, but only 14 of those are insurance programs. So the question as to how states would go ahead with this benefit is questionable. We see that the children's health insurance program, which we've been implementing over the last few years, takes time to implement. And certainly any program takes time to implement. The question is, in what direction should we get started? And Vice President Gore would start us immediately focusing on a Medicare benefit.
JIM LEHRER: Ms. Wilensky and all, much has been said that your two candidates in particular have a philosophical difference in the whole approach toward providing prescription drugs. Do these two plans reflect that, beginning with you, Ms. Wilensky?
GAIL WILENSKY: I believe they do. If you look at what Governor Bush has proposed, he wants to have modernized Medicare offered as part of a package of benefits prescription drug coverages -- either through the traditional Medicare with the high option, or through a variety of network plans or HMO's or any other type of insurance plan that people find meets their needs. It is not an attempt to have direct control over prescription drugs, but to try to offer individuals the opportunity to find health care plans, the traditional or others, that meets their needs. That is a very different way of looking at prescription drugs, but the emphasis on modernizing Medicare at the same time indicates that we recognize it's not just prescription drugs that needs to be modernized.
JIM LEHRER: Do you agree, Ms. Feder, that the basic difference of the approach is there?
JUDY FEDER: There is a basic difference in the approach. The Vice President believes that from the outset, the very beginning, that we need to move to legislation to incorporate a meaningful prescription drug benefit for all Americans into the Medicare plan.
JIM LEHRER: How do you see that, Mr. Reischauer?
ROBERT REISCHAUER: Well, I see this as the season where candidates try product differentiation, even though there isn't a whole lot of difference between each one's new and improved version. The President put forward a rather extensive and detailed plan to modernize Medicare that is not a whole lot different in general approach from that which the Bush campaign is working off of, which is really the Breaux-Frist approach.
JIM LEHRER: Senators Breaux and Frist had a plan for reforming Medicare that didn't go anywhere.
ROBERT REISCHAUER: Right. But neither did the President's go very far. So we're stalemated there. Each side is professing that it has something totally different from the other, and it's really just not the case.
JIM LEHRER: Not the case, Mr. Moffit?
ROBERT MOFFIT: I respectfully disagree. If you look at the Bush proposal, there are striking similarities between what Governor Bush is proposing and the Breaux-Thomas Medicare bipartisan commission proposal that surfaced last year. That proposal was based on the federal employee's health benefits program which today covers members of Congress and White House staff and federal workers and retirees. That plan is based on a pluralistic competitive model. Federal workers and retirees can take all kinds of different plans, all those plans have prescription drug coverage. Most of those plans cover between 80 percent and 90 percent of the cost of those drugs, and nobody has to go out and buy supplemental insurance in order to protect themselves against the financial devastation of catastrophic illness. So we're talking about a pretty profound difference here. If you look at the Gore proposal, it maintains the regulatory structure of the old Medicare system, and expands it. And if you look at the Health Care Financing Administration's power, it's pretty significant.
ROBERT REISCHAUER: You know, I'll join Bob Moffit in his plan; unfortunately, it's not what the Gore and Clinton folks have proposed. This... they have put forward basically an expanded Medicare plus choice plan where you can choose PPO's, HMO's, IPA's, the whole kit and caboodle that we had available for traditional Medicare and you can choose them with or without prescription drug benefit. You can get your prescription drug benefit through the traditional Medicare program, through your employer, wrap around policy if you're a retiree, almost anywhere. This isn't one size fits all.
JIM LEHRER: But is it fair to say, Ms. Wilensky and Ms. Feder, that somebody casting a vote on election day and they're concerned about prescription drugs for the elderly, either way it's going to come?
JUDY FEDER: No. And the reason is that it's very... If you start out focusing on a low-income program, I don't think it's reasonable to count on a direction of getting a guarantee, particularly since I think there are considerable differences in the long run visions. I'll comment if we have time.
JIM LEHRER: Ms. Wilensky?
GAIL WILENSKY: There certainly are differences between these programs. I think anybody who looks at what Governor Bush is proposing will understand that all individuals, all seniors are included under his proposal and the attempt to have this block grant to states is the concern that we'll have a year or two or three while the program is being implemented. We want to make sure seniors don't have to choose between food and drugs now.
JIM LEHRER: Reischauer, Moffit, is the argument over how you get there or whether to get there?
ROBERT REISCHAUER: We're going to get there, no question about it. The ball has begun rolling downhill, and no politician can stop it at this point.
ROBERT MOFFIT: It's how you get there, Jim. Look, 10, 20, 30 years from now, all these political debates about the details of different plans are not going to matter. I mean, what will matter 10, 20 or 30 years from now is whether our kids are going to want to know whether in fact we faced up fought problems facing Medicare and provided their parents and grandparents with a prescription drug coverage package which is responsible but at the same time recognizes there is personal freedom and personal choice.
JIM LEHRER: We have the leave it there. Thank you all four very much.