· Should patients be allowed to sue HMOs? · Should there be universal coverage for the uninsured? · What should be the future direction of Medicare?

Healthcare has been one of the most widely discussed issues in the 2000 presidential campaign. An estimated 44 million Americans - one in six - have no health insurance, including 11 million children. In 1999, 91 percent of employees with health insurance were enrolled in managed care plans, and over the past two years, 87 percent of doctors report that their patients have been denied coverage for certain health services by their health plans.

Patients' rights have become the battlecry of those who are dissatisfied with managed health care and want to protect consumers through legislation. States have been the first to address this issue; however, legislation widely varies throughout the country, and not all states have enacted patients' rights legislation. Currently, members can sue their health plan regarding payment or coverage but the potential results vary according to their state and type of plan.

Another widely debated topic this year has been Medicare reform. Medicare provides health insurance to 39 million elderly and disabled - about one out of seven Americans. This number is estimated to double over the next 30 years. Since 1966, Medicare has covered basic medical services for the elderly and disabled, and it is financed by a combination of taxes, beneficiary premiums and general revenues. It is the third largest government program and in 1999 accounted for 12 percent of the federal budget. The rapidly growing aging population combined with escalating medical costs have led to concern over Medicare's future solvency.

Medicare generally does not pay for prescription drug coverage. While two-thirds of Medicare beneficiaries receive prescription benefits through retiree insurance, private plans, Medigap or Medicaid, more than one-third do not receive any prescription drug coverage. In 1998 the prices of the fifty most prescribed drugs for the elderly rose by more than 4 times the inflation rate for the year. For many seniors, the availability of prescription coverage influences whether they fill their prescriptions at all.

As a senator, Gore co-sponsored legislation on women's and mental health issues, and as vice president he has been an outspoken advocate for a patients' bill of rights, as well as the Family and Medical Leave Act. He has pledged to make HMOs more accountable, expand access to health care coverage and strengthen Medicare. In the third debate, Gore accused drug companies of spending more money on advertising than research and development. He wants to streamline the approval process for generic drugs and promises to bring drug prices down by encouraging competition. Bush criticizes Gore's health plan as "a roadblock to reform" and charges that since the Clinton-Gore administration took office, 4 million more Americans have joined the ranks of the uninsured.

Gore has repeatedly challenged Bush's record on health care as governor of Texas. Bush inherited a state with one of the nation's worst public health records, but was a reluctant reformer.

In 1995, Governor Bush vetoed a patients' rights bill approved by the state legislature. In 1997, he threatened to veto another patients' bill of rights, in part because he did not support the provision allowing patients to sue HMOs. The bill passed the legislature by a wide margin and Bush allowed it to become law without his signature. Bush promises to make reforming Medicare a priority in his administration. "Medicare is an enduring commitment of our country, but it must be modernized for our times," he says. He wants to make healthcare more affordable for both individuals and small businesses, and to empower individual choice.



Should patients be allowed to sue HMOs?

Gore is a strong proponent of a patients' bill of rights to cover all insured Americans, and advocates giving patients the right to sue health plans for delaying or denying medical care. He supports the Dingell-Norwood bill which allows patients to sue HMOs and is now pending in Congress.

Bush also supports allowing patients to sue their HMOs, and takes credit for passing Texas' patients' bill of rights. However he has said he does not believe federal law should supercede state laws.

Should there be universal coverage for the uninsured?

Gore believes that the US should move "step by step" towards a universal healthcare system, though he does not believe the government should operate such a system. He promises universal healthcare access for children, and estimates that all children can be insured by 2004 by expending the federal Children's Health Insurance Project (CHIP). He proposes a 25 percent tax credit to encourage small businesses to provide health insurance. Gore opposes expanding Medical Savings Accounts because he believes they would benefit wealthier Americans.

Bush does not believe in universal health care. In the third debate he said, "I'm absolutely opposed to national health care plan. I don't want the federal government making decisions for consumers or providers." He would provide tax credits to help people buy private insurance, and expand Medical Savings Accounts, which he believes allow more Americans affordable access and choice. Bush advocates a "Family Health Credit" that would pay for 90 percent of an insurance policy, up to $2000 per year, for families making less than $30,000. He proposes allowing small businesses to link together in larger insurance pools to drive down insurance costs. He would relax federal rules to allow states easier access to federal funds under CHIP and provide $3.6 billion over five years to create 1,200 new community health centers.

What should be the future direction of Medicare?

Gore proposes putting Medicare in a "lock box," so that its surpluses, which could be as high as $400 billion over the next decade, can only be used to shore up the program. Critics say this proposal is risky because the surplus is dependent upon a sustained economy and not necessarily guaranteed. He would maintain the existing structure of Medicare, but add prescription drug benefits to all beneficiaries. He would allow seniors to choose their health coverage and doctor, and increase the penalties for health plans that choose healthier patients over riskier patients. Gore believes that Americans between the ages of 55-65 should be able to buy into Medicare and opposes increasing age eligibility. · (More on Gore's Medicare plans.)

Bush has proposed a comprehensive Medicare overhaul which he says will modernize Medicare by giving seniors the choice to select from a variety of benefits. While this program is being phased in, he would provide states with an "Immediately Helping Hand" - a program of $48 billion to help seniors with prescription drug coverage. Bush supports tax breaks to help people buy long term care insurance, as well as tax exemptions for those caring for elderly dependents. Bush also opposes increasing the eligible age for Medicare. · (More on Bush's Medicare plans.)

· FRONTLINE's Dr. Solomon's Dilemma
FRONTLINE examines doctors' dual responsibilities to their patients and their bottom line in the age of HMOs.

· Center for Patient Advocacy

· New York Times Healthcare issue guide (requires free registration)

· "Healthcare: A bolt of civic hope"
(The Atlantic Monthly)

· The Texas public health record
(The New York Times)

· On HMOs, Bush was reluctant Reformer
(The Washington Post)

· League of Women Voters & Kaiser Family Foundation Guide to Health Issues in the 2000 Election