Who Will Swallow Medicare's Bitter Pills?

Lorene Chandler's day begins with a pale green plastic tray and a glass of water. Popping the top of one of the tray's compartments, each marked for a day of the week, she pours out a handful of pills. Capoten, for blood pressure, comes first, on an empty stomach, and then come nine others, with coffee and orange juice and her Grape-Nuts cereal. Like many seniors, Chandler, 79, takes part in another regimen at the end of each month: she gets a ride from her home in Corrigan, Texas, to the drugstore where she sometimes pays as much as $300 to keep her trays--she has a second one for bedtime doses--filled with Atenolol, Imipramine, Norvasc and other drugs. When she is done, much of her Social Security check is gone. "There's not very much left for food," she says. "But growing up during the Depression, it learned me how to save on groceries."

What you have just read is not a political ad--at least not yet. But by the end of the summer, Chandler may well have film crews in her living room. She and the nearly 40 million other Medicare recipients whose drug bills are not covered by the government's health plan for the elderly will be at the center of a high-profile joust between the President and Republicans. Both sides plan to introduce some kind of prescription-drug benefit into the Medicare system while retrofitting the 34-year-old program to keep it from collapse. Even before Clinton could formally announce his plan, scheduled for this week, the Republicans attacked his proposed premium increase as a tax hike, labeling the whole plan another sneaky attempt at government control of health care. Many Democrats are spoiling for a fight, hoping a messy display might win back the hearts of seniors who embraced the G.O.P. in the past two elections.

Nearly 80% of seniors take at least one pill a day, according to a recent survey. The number of medications in development for diseases associated with the elderly has grown from 225 a decade ago to 648 today. The increased number of prescriptions and the rising cost per pill mean seniors are on a treadmill of ever increasing expenditures. In the past five years national spending for all prescription drugs increased almost 60%. That pace is expected to continue. As seniors become more dependent on these remedies, they are also subjecting themselves to the increasing cost of the medicines. While only a third of Medicare recipients are completely without drug coverage of any kind, many of those who buy supplemental insurance through former employers, Medicaid, HMOs or Medigap must still pay a stiff part of their drug costs.

Medicare was a treacherous battlefield before anyone suggested a new entitlement. Most experts agree that adding items and fundamentally reforming Medicare will require some kind of sacrifice by beneficiaries, either paying higher premiums or delaying the eligibility age. But suggesting such reforms may carry a high political price. "There are some in both parties who want the election to be based on whose fault it is we did nothing about Medicare," says Democratic Senator John Breaux, whose yearlong Medicare commission failed to come to consensus largely over the issue of how much coverage to provide for drugs. Says Breaux: "Republicans want to blame Democrats for how badly the system works, and Democrats want to say that Republicans are cutting your benefits."

For many Democrats, it will be tempting to dangle cheaper prescription drugs to win back elderly voters who were once a fundamental part of their voting base. Exit polls after the 1998 election show that elderly voters picked G.O.P. candidates by 55% to 45%. In polls measuring the 2000 presidential race, Al Gore trails George W. Bush by 20 to 30 points with a group of voters who tend to pick Reagan rather than F.D.R. as their political hero. Strategists from both parties suggest that a reason for the shift may be recent headlines. As one Democratic puts it, "When it's about Social Security and Medicare, we win. When the debate is about Monica, we lose."

Republicans read the same polls and are prepared to pry seniors and the Democrats further apart with the G.O.P.'s own plan, which they have yet to design but which they promise will cover the poor and acutely ill. With strong backing by drug manufacturers, most in the G.O.P. will fight any plan to provide a universal benefit of the kind Clinton is suggesting, as well as other measures being offered by Democrats that would lower the cost of prescription drugs for Medicare patients. The only way such a system could work, they say, is through price controls set by Washington bureaucrats--and that, the G.O.P. argues, would ultimately drain drug companies of the profits that allow them to finance research that leads to even better products.

The proposals will not make downing those pills any easier for Lorene Chandler, but they can do something to keep her trip to the pharmacy from leaving her with almost no money for anything else in her life.