“Bush really anguished with his advisors, worried if he didn’t come up with anything significant, maybe it would be better not to be active on the issue,” said Robert Blendon, a Harvard University professor who has tracked public opinion on health care for more than a decade. “They decided there’s enough interest to do something on this problem or else it would look like he was neglecting a major issue.”

The cornerstone of the Texas governor’s plan is to give the uninsured up to $2,000 in tax credits so they can go on the open market and buy coverage.

Gore’s plan would mainly help children and their families. His proposal relies on an expansion of Medicaid, the health-care plan for the poor, and the Child Health Insurance Program, the state-administered federal program that helps low-income children.

While the details of their plans are different, both take an incremental approach. There are no sweeping plans on either candidate’s mind. And that’s probably just fine with the majority of the American public. “This is not the era to try to cover everyone,” says Blendon.

Not surprisingly, Democrats and health-care advocates charge Bush’s plan doesn’t go far enough. They say the $2,000 in tax credits he is proposing wouldn’t enable the poor to buy health insurance because family policies typically cost more than that.

But Republicans and business interests say Bush has it right — that the purchase of health care should remain a free-market issue. They want to avoid a government-run system at all costs.

Robert Desposada, president of the Hispanic Business Roundtable, says even if $2,000 a year won’t pick up the whole tab for a family’s insurance, it will be enough of a help that business may pick up the rest.

“The fact is the problem with a good chunk of the uninsured is that these are people who work for small businesses and the service industry whose companies do not offer health insurance,” said Desposada, who owns a public relations firm in Alexandria, Va.

“This is an approach I think will be helpful. I can’t give my employees $2,000 a year. I can give you a part of the difference that it will take for you to get health insurance.”

Bush’s plan is also similar to bipartisan proposals in both the Senate and House. House Majority Leader Richard Armey, R-Texas, and Rep. Cal Dooley, D-Calif., introduced a bill a couple of weeks ago that is also tax-credit based. The same measure has been introduced in the Senate by Sen. John Breaux, D-La., and Sen. Bill Frist, R-Tenn., who is also a heart-transplant surgeon.

But Families USA, a health-care advocacy group that has been pushing for universal coverage, calls Bush’s proposal “a trivial response to a serious problem.”

Families USA executive director Ron Pollack says that a typical family health plan costs $5,000 to $6,000 a year and even with the $2,000 tax credit, that leaves a $3,000 to $4,000 balance that won’t be picked up by employers and would be unaffordable for low-wage families. To many health-care advocates, Gore’s proposal looked paltry when set beside former Sen. Bill Bradley’s plan for getting to universal coverage quickly.

But if forced to choose between Bush’s plan and Gore’s plan, they will side with the vice president. Beyond the issue of how many people would be covered under each plan, Brookings Institution senior fellow Henry Aaron worries that Bush’s plan might erode the employer-based coverage by creating a shift toward individual coverage.

“If we unwind the system of workplace-based coverage, short of having subsidies larger than anyone is talking about, then we’ll discover at the end of the day that we have fewer people insured than more,” Aaron contends. Since companies buy health insurance policies in bulk, the process keeps costs down, Aaron said. Without that buying power, the individual market has more overhead and administrative costs.

Blendon sees a road to compromise on the issue. While he doesn’t believe any such deal could surface during the campaign season, Blendon thinks the two proposals could work simultaneously.

“I could see that for people at the most modest end the public programs are extended, but for people who are working and have a bit higher income you could have tax credits,” Blendon says. “That’s a basis for a compromise.”

It’s called DTC advertising: direct-to-consumer. “The
No. 1 story in health advertising is this boom in DTC
advertising,” says David Goetzl, who has followed this
phenomenon for Ad Age magazine. According to IMS Health, a
London-based analyst, pharmaceutical companies in the United
States spent $529 million on such television advertising for
the first half of 1999, a 68 percent increase in spending
over the same time in 1998.

Claritin, medicine for controlling allergies, is the mother
of all of this advertising. It was the top-spending brand
for TV advertising at $48 million. Last fall the product was
even linked with baseball. “They called themselves the
official allergy medicine of Major League Baseball,” says
Goetzl. That’s marketing strategy you usually associate with
cars, airlines or soft drinks. After Claritin, the leaders
were Propecia ($42 million), Meridia ($29 million), Nasonex
($29 million) and Flonase ($25 million).

The difference between this advertising and the usual direct selling to consumers is that the person who sees
the ad can’t go right out and buy the product. They have to
get their doctor to agree to write them a prescription.

Dr. Alan Sheff, an internist in a Maryland suburb of
Washington, sees pluses and minuses in this new
phenomenon. “Taking the positive side, I think many patients
are unaware of newer treatments that are available and
effective for conditions,” Sheff says. He used heartburn as
an example. A patient may see an add for a heartburn drug
and instead of continuing to pop antacids they may go to
their doctor and find out they have digestive problems. Or
take the Valtrex ads for the suppression of herpes. That ad
might bring people into the physician’s office to get
treatment even when they’re not having an outbreak.

Sheff also thinks such advertising could break down some
fears or hesitancy some patients have about taking their
medicine. “If I have to prescribe a medication and they’ve
heard of it because they’ve seen it associated with pretty
pictures on television, it might lower their resistance to
taking it,” Sheff says.

That’s the kind of thing the drug manufacturers want to
hear. At Schering-Plough, the makers of Claritin, executives
don’t talk about their marketing strategies or how effective
their ad campaigns have been. “We believe such advertising
can play a key role in informing the public about meaningful
advances in drug therapies,” says Bill O’Donnell, a
spokesman for the New Jersey-based company.

There is a downside, doctors say, to the barrage of television ads. “My greatest concern is what this does to health care and
pharmaceutical costs,” Sheff says. “The advertising has got to be expensive and you better believe the medicines that are advertised are not available by generic. They are among the most expensive medications on the market and so I have great
concerns about forcing my patients to pay for all that direct-to-consumer advertising for these expensive medications.”

One reason for the boom is the government’s
clarification of the rules of this advertising. The Food and Drug Administration rules on drug advertising date back to 1969, explains Nancy Ostrove, branch chief in the division of drug
marketing, advertising and communications. Those early regulations said if a drug manufacturer wants to tell people what its drug does, it also has to give the possible side
effects. Because manufacturers didn’t really want to give the downside, they were getting around those regulations by just mentioning the name of the drug or talking about a malady that could be helped without mentioning the name of a drug.

“That was causing a lot of confusion,” Ostrove says. “Consumers and
patients were going to the doctor asking for things that were totally inappropriate for them.”

So in 1997 the FDA updated the regulations. They now say that prescription drug ads have to give the whole story — the benefits and the possible side effects. For example, an ad for Tamiflu shows a young woman in pajamas in her bedroom, obviously down and out with the flu. She reaches for a glass of orange juice. In a very soothing voice, an announcer says there is more help for her — Tamiflu. That calm slow voice continues and, after all of the wonderful possibilities for the drug’s effectiveness are explained, the announcer says, a bit more quickly, “One in 10 may experience mild nausea or vomiting.”

In addition, the ads have to give consumers a way to find out more about the drugs. They should include an 800 number, a Web site and reference to a print ad about the drug, and they must advise people to talk to their doctors.

“For the most part what we’re seeing is reasonable since the 1997
regs,” Ostrove says. Drug manufacturers are required to send the FDA copies of all their promotional materials for review, she says, and so far they haven’t seen any adverse effects from the ads.
Ostrove said the biggest risk she sees from this type of advertising is the possibility of “trivializing prescription drugs.”

“There’s the risk of patients now believing that their doctors aren’t
necessary to make the decisions about whether to take a drug,” Ostrove says. “There’s a belief that perhaps it will affect the
patient-physician relationship.”

Dr. Edward Benz, chairman of medicine at Johns Hopkins University in Baltimore, sees a potential danger in that a little knowledge of these drugs could be dangerous. “An ad is a sound bite and a sight bite that’s on for 30, 40, maybe 60 seconds tops,” Benz says. “For something as important and complicated as a potent medication, I don’t think that’s enough time for people to
be forming judgments.”

Some consumer groups agree. “The only reason behind this advertising is to create demand for product,” says Larry D. Sasich, a pharmicist at Health Research Group, a unit of Public Citizen in Washington, D.C. Sasich points to an article in Medical Marketing and Media, an industry trade journal. “That piece said that over the years the purpose of these ads is to drive consumers into doctors’ offices to ask for brand-name drugs.”

Industry spokespeople say the aim is to educate. “We believe that a well-informed patient is more apt to obtain appropriate and effective treatment,” says Schering’s Robinson. “That’s the reason why we’ve implemented a patient information program.”

“I am elated that health care is an issue in the campaign,” Clinton told reporters in the Oval Office. “It is a good thing. It’s an issue in people’s lives.”

Unlike in 1993 and 1994, most of these proposals take an incremental approach to the insured problem. Clinton’s plan would only handle 5 million of the 44 million uninsured. And his plan is taken directly from Vice President Al Gore’s proposal.

Gore’s proposal goes further than Clinton’s but not as far as former Sen. Bill Bradley’s, which promises universal coverage. Few politicians other than Bradley have come forward with anything resembling Clinton’s complete overhaul of the health-care system.

A new survey done by the Kaiser Family Foundation and the Harvard School of Public Health supports the decisions of candidates to pay attention to health care. And it validates the decision to take it slowly. Health care was cited as a top issue by 28 percent of voters surveyed. That is the highest that health care has scored on such as survey in recent years. In 1998, for example, health care was ranked highest by only 12 percent of the population.

And, according to the new survey, health care will be especially important in capturing the women’s vote. Of those who picked health care as a top issue, 61 percent were women. But the public doesn’t agree on how to cover the nation’s uninsured. Of the registered voters Kaiser surveyed, 43 percent favored making “a limited effort” that would not result in a tax increase. And 39 percent would support insuring all Americans, even if a tax increase were needed, while 12 percent supported the status quo.

The concentration on health care is most notable on the Democratic side of the campaign trail. While Bradley and Gore have gone at it over whose health plan would help the most people and is most feasible, the Republican contenders have been almost silent on the issue.

Again, Kaiser’s survey validates that this is an important primary strategy for both sides. The survey found a 23 percentage point gap (56 percent to 33 percent) between Democratic and Republican registered voters who say covering the uninsured is a top priority for using any budget surplus.

While the GOP contenders have been quiet on the stump, congressional Republicans insist they had a plan to increase coverage last year but the president nixed it. “Congress’s top health-care priority is helping more Americans get health insurance, but unfortunately, the president last year vetoed our plan do that,” says Rep. Bill Archer, R-Texas, chairman of the Ways and Means Committee.

The GOP congressional plan provided 100-percent tax deductions for people who buy health insurance and an expansion of medical savings accounts. But it did not include any subsidies for people who could not afford health insurance.

Clinton’s proposal builds on the Child Health Insurance Plan under which states help insure children either by getting them on Medicaid or through a subsidized program for children whose parents are poor but earn too much to qualify for Medicaid. Under the new plan, Clinton wants to add 400,000 children to those plans and would insure them through age 20 (More than 2 million are covered now.) And he would add their parents to the program.

Another proposal, ignored by Congress last year, would resurrect Clinton’s plan to allow workers as young as 55 to buy into the Medicare program. The president would also give a 20-percent tax credit to small businesses as an incentive for them to offer health insurance.

The Health Insurance Association of America spent $17 million on its battle to convince America that passage of the Clinton health plan would be devastating. They said people would lose their choice of doctors, that insurance would become so expensive employers would drop it. And on it went. Now the trade association for many of the nation’s health insurance companies is spending an initial $1 million on its “InsureUSA” campaign.

The commercials are still set around Harry and Louise’s kitchen table. There’s still a cup of coffee on the table. But there’s something new. Harry and Louise are now poring over a laptop computer. And they’re talking about e-mailing instead of writing to politicians.

As word spread through the nation’s capital that this fictional couple was back, health-policy wonks and lobbyists howled. And then they talked about the irony of the health insurance industry’s seeming turnaround.

“I guess they’re trying to salve their conscience,” said John Rother,
senior lobbyist for the American Association of Retired Persons and one of the key architects of the effort to get Clinton’s plan enacted. “It is surprising that they would use the very same people that are identified with the negative, with killing health reform, to argue for expanded insurance.”

Not so, says Richard Coorsh, chief spokesman for HIAA. Coorsh says HIAA has always been for universal health coverage; it was
just Clinton’s ideas that the industry did not like. The ads started running Wednesday and will be on CNN through Jan. 30. They will run in the nation’s major newspapers, including
the Washington Post, the New York Times and the Wall Street Journal.

Of course, the motives behind this plan are not strictly altruistic.
The more people with health insurance, the more business for HIAA’s 290 member companies. The HIAA plan basically builds on the current employer-based health insurance system, and includes tax provisions allowing individuals to deduct 100 percent of health insurance premiums, and special provisions for small employers with low-wage workers.

And there are government subsidies for the poor. Anyone earning up to 100 percent of the federal poverty limit who
doesn’t have health insurance would be eligible for government
coverage, similar to the plans now provided by the State Health
Insurance Program. For the so-called working poor, those earning between 100 and 200 percent of the poverty limit, vouchers worth about $2,000 a year — about 75 percent of the health premiums — would be available. The plan would cost $50 billion a year.

During Clinton’s health-reform effort, the HIAA was pretty much aligned with the Republicans, and a former Republican congressman was its president. Now a former Capitol Hill health staffer, Chip Kahn, is the group’s president. But that’s where any Republican connection stops.

HIAA’s plan sounds remarkably like the one being hawked by former Sen. Bill Bradley. It goes even further than the one Vice President Al Gore has suggested. And so far nothing like it has been suggested by any of the GOP hopefuls.

The ad campaign is timed both to the presidential campaign season, the president’s State of the Union address next week and next week’s return of Congress. “We think this is the most important domestic policy issue,” said Coorsh.

If the past is any indication, this first $1 million media buy will not be the last for the HIAA in this campaign. When asked what’s planned next Coorsh would only say, “Stay tuned.”

The stigmatization of and inadequate insurance coverage for mental illnesses has been documented for some time. But this report puts a federal emphasis on the problem and gives advocates new ammunition to continue to push for parity for mental health coverage. The report described mental illness as “a diagnoseable mental disorder” and says that mental illness, including suicide, is “the second leading cause of disability” next to heart disease.

The 500-plus page volume is the result of an exhaustive review of more than 3,000 studies on mental illness.

“Despite unprecedented knowledge gained in just the past three decades about the brain and human behavior, mental health is often an afterthought and illnesses of the mind remain shrouded in fear and misunderstanding,” the report says.

Typically, health plans have some mental health coverage but often it limits office visits and doesn’t guarantee hospital stays. And under managed care, mental health coverage is also managed by a company separate from the medical health plan that covers the rest of the body.

“One would hope that we’ve come a long way from the myth and cliche of the Woody Allen syndrome,” said Bob Carolla of the National Alliance for the Mentally Ill. “Treatment sometimes involves a combination of talk therapy, but also with several mental illnesses, you’re oftentimes talking about medication and there are a range of treatments that have to be individualized.”

In recent years Congress and the states have taken up the issue of mental health parity. In 1996 Congress passed a bill with the goal of having physical and mental illnesses treated the same. But that bill had loopholes, advocates say, and they want federal legislation to plug those holes. The 1996 law did not provide for a minimum number of in-patient days or out-patient visits that have to be covered. And it exempted businesses with fewer than 50 employees. The bill was also silent on such issues as co-payments, deductibles and other out-of-pocket costs.

Some 28 states have a form of parity legislation, Carolla said. But the models for the nation, he added, are three bills passed this year in California, New Jersey and Virginia. And President Clinton signed an executive order that will take effect in January giving parity for mental health coverage for some 9 million federal employees.

The insurance industry says the answer isn’t mandates. The coverage is there, they say, it’s up to employers to decide to provide it. “The employer community is betwixt and between,” said Richard Coorsh, spokesman for the Health Insurance Association of America. “On the one hand they’re eager to continue to provide coverage for their employees. On the other hand they have to deal with health care cost increases which translate into higher premiums. Therefore, adding additional cost can provide an impediment to additional coverage for mental health services.”

The report falls short of calling for exact parity with the rest of the health care coverage, but says equal coverage should be “an affordable and effective objective.”

“This report underscores the need to continue to strengthen our nation’s mental health system and fight the stigma associated with mental illness so all Americans can get the treatment and services they need to live full and productive lives,” said Tipper Gore, wife of Vice President Al Gore. She has made identification and treatment of mental illness a top priority.