Whose Pill Is Sweetest?

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The insurance companies claim they cannot make a profit on the amount Medicare reimburses them for coverage, and they are stymied by tens of thousands of pages of rules for providing services under the program. Bush promises to modernize the regulations and the fee structure--he would add $150 billion more to Medicare over 10 years--but has provided little detail on how he would do so. He cites the popular health program for federal employees as a model for the structure he would set up for Medicare, but critics say the experiences of that younger, healthier government work force have little to do with those of the elderly. Many of the elderly have not been happy either with how managed care has treated them so far. They have become increasingly disillusioned by the HMOs' cutbacks in drug benefits and by their rising premiums and co-payments.

When it comes to prescription drugs for the needy elderly, the first experiment with the free market has yet to work. Nevada last March invited hundreds of insurance companies to bid on its new program providing drug coverage for low- and moderate-income people age 62 and older, but only one insurer responded--and it was disqualified because it was not licensed to do business in the state. Nevada reworked its plan, making clearer what it expected of the companies, and got five proposals in time for a second deadline, in August. The state is reviewing the proposals.

Bush boasts that his plan, while more modestly priced than Gore's, gets prescription help faster to the neediest elderly, by handing states $48 billion and telling them to deal with the problem until Bush's broader reforms solve it. But only 16 states have drug-assistance programs in operation (six others have passed laws to start them), the benefits they offer vary widely, and the Governors have said they don't want the responsibility. What's more, experience with other programs--like providing drug benefits through Medicaid--suggests the states are far less efficient than the Federal Government at enrolling those who are eligible.

At a minimum, Bush has started a national debate over the future of Medicare that many health experts say is overdue. But no one will know how workable his ideas are until he comes up with more details. And the more he spells out the fine print of his plan, the more difficult it may be for him to get Americans to accept it. Because that's how health-care politics works. Hillary Clinton could have told him that.

With reporting by John F. Dickerson/Washington and Mitch Frank/New York