1. Stubenrauch, James M. senior editor

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On Sunday, July 18, National Public Radio's All Things Considered reported that health care policy, which many experts predicted would be a major issue in the presidential campaign, has so far "failed to register" with voters. Among the factors cited was the tendency of those without health insurance to be among those who don't vote. But the story also suggested that both major-party candidates have, in their own ways, downplayed health care. David Durenberger, formerly a Republican senator from Minnesota and now a health policy consultant, said that by focusing almost exclusively on the recently passed Medicare prescription drug legislation, the Bush administration "has done an excellent job of making, whether it's health care for the uninsured or health care costs, a nonissue in this campaign." And, while Senator Kerry has made far more ambitious proposals for insuring the uninsured and reducing health care costs, he has also failed to highlight these proposals to the degree that many hoped he would, perhaps in fear of being branded a tax-and-spend Democrat.


Other commentators, including Howard Kurtz writing in the July 20 Washington Post, have blamed the news media for a preoccupation with style rather than substance and a "lack of interest in policy issues"-saying, in effect, that health care isn't of primary concern to voters because the media haven't made it one.

FIGURE. President Ge... - Click to enlarge in new windowFIGURE. President George W. Bush addresses the National Conference on Human Trafficking, July 16, 2004, in Tampa, Florida.

In an effort to counteract this trend, we offer the following comparison of several of the candidates' proposals.



The problem.

Approximately 44 million Americans didn't have health insurance in 2002; almost 82 million-one out of three people younger than age 65-were without health insurance during at least part of 2002 or 2003. About 80% of the uninsured are members of working families. The rising cost of health insurance has been documented by a Kaiser Family Foundation report, which said that health insurance "premium increases significantly outpaced both the rate of inflation and the growth of workers' earnings in almost all years since 1988," reaching double-digit increases in the past three years. Employer-sponsored health insurance premiums averaged about $3,300 for individuals and $9,000 for families in 2003. (To see the Kaiser report, go to


The Bush proposal.

The president advocates a refundable tax credit to help people with low and middle incomes who aren't already insured to buy health insurance. A family of four with an income of $25,000 per year would be eligible for a tax credit of $3,000; for a family with an annual income of $40,000, the credit would be $1,714. The Treasury Department estimates that the tax credit would extend insurance coverage to 4.5 million people (approximately 10% of the uninsured) at a cost to the federal government of approximately $90 billion over 10 years; however, the Kaiser Family Foundation estimates that the number of newly insured would be closer to 1.8 million.


The president also supports the creation of association health plans (AHPs), in which small businesses would group together to have the same access to lower rates that large corporations and unions have. The Bush campaign Web site says that the Congressional Budget Office "estimates that by 2008, 7.5 million people would obtain health insurance through AHPs and 600,000 would be newly insured." (See


Health savings accounts are tax-sheltered medical expense accounts for those who purchase high-deductible insurance (which covers catastrophic illness), created as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The president has proposed that the premiums for such high-deductible insurance plans be made entirely tax-deductible.


The Kerry proposal.

Senator Kerry has put forth a health care plan that would extend health insurance to approximately 95% of all Americans, including virtually all children. The cost of the plan has been estimated at $653 billion over 10 years (see He would pay for the plan by rescinding the Bush tax cuts for those with an annual income of more than $200,000. (Kenneth Thorpe of Emory University estimated the cost of the plan independently, and an analysis by the nonpartisan Tax Policy Center supports the notion that the proposed tax increase for the top 3% of earners would pay for most of the cost of extending health insurance to an additional 27 million Americans.)


According to Kerry's health plan, in 2001 only 0.4% of private insurance claims were for treatments in excess of $50,000, but "these claims accounted for nearly 20% of medical expenses for private insurers." His proposed "premium rebate pool" would reimburse employers for 75% of costs above $50,000 "as long as they guarantee such savings are used to reduce the cost of workers' premiums." To be eligible for the plan, employers would have to offer affordable health insurance to all of their workers, pass the savings on to workers (Kerry hopes to reduce insurance premiums by 10% by this method), and encourage better management of chronic disease to decrease the costs of care.

FIGURE. Senator John... - Click to enlarge in new windowFIGURE. Senator John Kerry addresses the 95th annual National Association for the Advancement of Colored People convention in Philadelphia, July 15, 2004.

Kerry also proposes fundamental changes in the way the states and the federal government split the costs of Medicaid and the State Children's Health Insurance Program (SCHIP), the primary goal being to automatically enroll all uninsured children in Medicaid. The federal government would cover the cost of Medicaid for 20 million currently uninsured children if states agree to pay for those children enrolled in SCHIPs. This would also apply to all children of legal immigrants, who currently have to wait five years to become eligible. States would also be required to insure parents with incomes of up to 200% of the poverty level, as well as single and childless adults living below it.


Kerry also proposes that workers employed by small firms (fewer than 50 employees), the unemployed and those between jobs, and workers between the ages of 55 and 64 be made eligible for the same health plans offered through the Federal Employees Health Benefits Program, the program available to members of Congress.



The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 is the centerpiece of the president's health care program. Focused primarily on prescription medications, the law created temporary discount cards that provides some savings for qualified seniors and disabled people and will add a new prescription medication benefit to Medicare beginning in 2006 (see AJN Reports, July).


Senator Kerry opposed the legislation and has made a number of proposals for reforming Medicare and curbing the cost of prescription medications. These include allowing prescription medications to be reimported from other countries (opposed by the Bush administration) and permitting state governments and Medicare administrators to negotiate prices with pharmaceutical companies (forbidden under the current law). In addition, Kerry would close loopholes in patent laws that keep cheaper generic drugs off the market, and he proposes requiring pharmacy benefit managers-companies that manage drug benefits for the vast majority of insured Americans-to disclose the discounts and other financial incentives they receive from drug manufacturers.



There seems to be general agreement between Democrats and Republicans that the Nurse Reinvestment Act (NRA) was an idea whose time had come. Designed to address the nursing shortage, the NRA (PL 107-205) was coauthored by Senator Kerry and Senator Barbara Mikulski (D-MD), passed in both houses of Congress with strong bipartisan support, and was signed into law by President Bush on August 1, 2002.


The law amends Title VIII of the Public Health Service Act, which governs nursing education and practice. The NRA's new provisions include, for individuals, nursing scholarships and nursing faculty loan cancellation programs and, for institutions, grants that support internships and residencies, education in geriatrics, and retention and career ladder programs (the latter includes continuing education for nurses already in the workforce and educational partnerships between provider institutions and schools of nursing). The law also supports public service announcements that promote nursing and expands the types of sites that nurses can work in to fulfill the service commitment of the Nursing Education Loan Repayment Program. According to the Online Journal of Issues in Nursing, funding for the Nurse Reinvestment Act, which must be renewed annually, was $141.92 million in fiscal year 2003. The ANA had urged Congress to appropriate $250 million (see


In 2001 Senator Kerry cosponsored the Safe Nursing and Patient Care Act, which would limit the number of mandatory overtime hours a nurse can be required to work. According to the Kerry campaign, as president he would continue that commitment by supporting legislation to stop the dangerous practice of forcing nurses to work mandatory overtime.



Malpractice insurance and lawsuits.

President Bush blames frivolous lawsuits for the rising cost of malpractice insurance and advocates capping damages in medical malpractice cases. Senator Kerry opposes capping damages and would institute incentives and penalties that would reduce the number of meritless lawsuits.


Medical errors and administrative costs.

President Bush proposes technological solutions to reduce medical errors and administrative costs. His fiscal year 2005 budget request would, if adopted, increase funding for the development of health information technology, and he wants most Americans to have electronic medical records within 10 years. Senator Kerry's health plan incorporates many of the same technological solutions, including electronic medical records for all Americans by 2008, and also adds financial incentives to encourage providers to improve the quality of care.


Stem cell research.

Kerry and 58 other senators signed a letter to the president urging him to support federal funding for stem cell research. The president then decided that federal funds can be used to support stem cell research, but only research that uses existing stem cell lines.



To see where the candidates stand on health care issues, go to and To learn more about independent and third-party presidential candidates and their proposals, go to And don't let anyone tell you that health care policy is a nonissue.