Columns » Ernest Dumas

Hillarycare in action

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If you always had an academic curiosity about how Hillary Clinton’s ill-fated national health insurance plan would have worked if Congress had enacted it a dozen years ago you need only to follow the Medicare Part D drug program.

Hillarycare, the derisive name that critics gave the Clinton comprehensive insurance plan for all Americans, was the template for the prescription-drug service devised for the Bush administration by the insurance and pharmaceutical industries. Given three years to implement the Rube Goldberg plan that it had written itself, the Bush administration launched it Jan. 1 on the nation’s terrorized elderly poor.

So haphazardly was the plan administered that the nation was treated for the first time in its history to the spectacle of state governments, including poor Arkansas, rushing to bail out the federal government when sick people suddenly could not get the drugs upon which their lives depended because the national government that promised them couldn’t or wouldn’t deliver. They were the same state governments whose celebrated incompetence had fueled the great growth in federal action in the New Deal and in the expansion of federalism after World War II. How times have changed.

The comparison may not be entirely fair to the Clinton health-care plan that flamed out in 1994. Although it was equally bewildering and also premised on giving the insurance and drug industries a big cut of tax-financed medical spending, we might have expected the Clinton plan to at least be administered competently by a government that actually believed in it.

There should have been no such expectation that the Bush administration either could or wanted to flawlessly insure the prescriptions of the elderly middle class and the poor. Government now exists for corporations and the affluent. Prescription coverage for the elderly was a political expedient dreamed up by Karl Rove to blunt a popular Democratic initiative. No one cared if it worked particularly well. A government that had proved itself inept in almost every other undertaking except growing the wealth of the super rich was not going to efficiently expand a government service that it hated.

The Clinton plan and the Bush Medicare drug program delivered benefits in the same way. Clintoncare would have had businesses, workers and the self-employed in each state or service region select from an array of supposedly competing private health plans with the government serving only as a pass-through for the financing. The Clinton plan would have made the selection easier than the nightmarish Bush plan but probably not by much.

Simply expanding Medicare to cover drugs would have been simpler and would have given people far greater coverage for the dollars. The Bush administration would not have had to lie to Congress about the costs and threaten the career of the Medicare actuary when he wanted to give Congress and the public the real figures. (By the way, was there an independent counsel investigation for that crime?)

The instant crisis is the inability of the government and the insurance companies to get the elderly poor whose prescriptions formerly were insured by Medicaid properly crossed over into one of the Medicare plans. State governments are paying druggists for the medicines now with the promise that some entity will pay them back real soon. But that is not the end of it. Wait until people pass their limits and hit the “doughnut hole” when companies stop paying anything on their drugs.

When you decide that tax receipts intended for health care must be siphoned off to supply ample profits for big insurance companies, one or both of two things will happen: drugs will be eliminated from coverage or you make people pay more through deductibles, copays and premiums.

Tens of thousands learned that this month.

Here’s one example. People who depend on a somewhat expensive heart drug called Niaspan to raise their good cholesterol, which is a key to preventing heart attacks and hardening of the arteries for many, found this month that the drug was not covered although it was on the formulary of nearly all the drug plans and as late as this week on Medicare’s own website. Since the compound includes niacin, which is found in vitamin supplements, which are not covered by law, the Bush administration decreed that insurance companies must not cover it.

Next week, his advisers having noted the rising poll numbers on public alarm over medical costs and evaporating employee health insurance, Bush is going to make health care the centerpiece of his State of the Union speech. His big solution will be his solution to every social and economic ill: provide a big tax advantage to those who least need it. In this instance, it is an expanded tax-exempt or tax-deferred medical savings account — another tax shelter for people who have no trouble buying gold-plated health policies — along with more tax breaks. What good is a tax break for low-wage workers?

But government is not for them anyway. It is becoming exactly what the Republicans since Ronald Reagan have told them it was: the enemy. But Reagan never acted much on that notion. It is doctrine now, and we must get used to it.


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