Patient politics

Will healthcare be the albatross around George W. Bush's neck? Al Gore thinks so.

By Jake Tapper
Published August 24, 2000 8:00AM (EDT)

On Wednesday, the campaign of Gov. George W. Bush attacked Vice President Al Gore for failing to pass any long-term healthcare plans -- and the Gore campaign couldn't have been more pleased.

Bush's attack came as Gore and his running mate, Connecticut Sen. Joseph Lieberman, spent the day in Florida heralding their new long-term healthcare plan. But by even addressing the issue of healthcare, a senior Gore advisor says, Bush is playing into Gore's hands, opening the door for a winner of an issue for Gore -- and a big fat dead-weight loser for the Texas governor.

According to the Gore advisor, Bush's healthcare problem goes way beyond the Texas governor's proposals which, compared to Gore's new, costly prescription drug plan, will seem rather paltry. The problem even goes beyond "the Texas record, where there are some big problems," according to the advisor. As in "the huge number of uninsured, particularly children."

Healthcare is "going to be the focus of a lot of debate, for two reasons," the Gore advisor says. "One, it's important to people. And two, there are real differences between the candidates."

And three, the Gore campaign hopes to use the healthcare debate as a tool to show that Bush simply does not have what it takes -- the policy curiosity, the intellectual inquisitiveness, the awareness beyond self and the just-plain ready-for-prime-time vibe -- to be president.

"Put it all together and it's a losing issue for him," the Gore advisor says.

Bush's friends and foes alike concede that healthcare may be a weakness for the Texas governor in the fall. It "has not been a focus for the governor," says a Texas lobbyist who's knowledgeable about the issue, one who generally gives Bush good marks. "It's just not an issue he's been particularly interested in. It's not an area he's comfortable with."

Asked about the issue, Bush spokesman Dan Bartlett defended Bush's healthcare record and criticized the Clinton/Gore administration for a missed opportunity to overhaul the nation's healthcare system.

"Under President Clinton and Vice President Gore there are 8 million more uninsured Americans than before," says Bartlett. "And 2.4 million of them are children. Clinton and Gore had a golden opportunity, but their prescription was to have the government take over the healthcare system, which was rejected. It's yet another squandered opportunity."

Bush's prescription, according to his own literature, is to make "health insurance affordable for hard-working, low-income families" through "a $2,000 refundable health credit so that they can purchase their own insurance." For the average American family, that $2,000 falls anywhere from two to three thousand dollars short of what health insurance will likely cost, according to most independent analyses.

But Bush would clearly prefer to talk about other subjects. When the Texas Legislature introduced a "patient protection act" in 1995, Bush's first year as governor, "he strongly opposed it," says the lobbyist. Not on the merits of the issue, but because "he didn't want a debate on the subject, because it's not within his comfort zone."

"This is not a bad guy," says a longtime Texas political operative who's a Bush supporter. "It's just that he's a 3-by-5-card, consultant-driven, corporate-boardroom kind of guy." Thus, the operative says, Bush leans heavily on his staffers. And often the staffers give him advice that doesn't necessarily square with the facts and sentiments that a public debate on the issue might reveal.

Bush's lack of interest in the issue has been all too apparent to anyone watching TV or reading the newspaper. In March, asked by Dan Rather about the fact that Texas ranks 49th when it comes to women with health insurance, and 50th when it comes to children, Bush said, "I think you can find all kinds of statistics to make all kinds of cases. I rest most of my case on the fact that people in Texas like the job I have done ... I don't know the statistics ... but I do know there's a lot of women who are covered, and if there's work to do, we'll do it in the great state of Texas."

At a February campaign stop, a woman with a terminally ill son whose medical costs aren't met by her insurance asked Bush what he would do. Bush, according to the New York Times, "seemed stumped. He sang the praises of medical savings accounts, then acknowledged that it was too late for the woman to start one and that he really had no specific remedy for her. 'I'm sorry,' he said. 'I wish I could wave a wand.'"

So what kind of a doctor will Bush be if he does get elected? Based on what he's done in Texas, it seems clear that what Bush might actually think about an issue, were he willing and able to study it in depth, can get lost in a whirlwind of big-money interests, hardscrabble politics and spin. And nowhere in his Texas record does this aspect of Bush's personality manifest itself more clearly than on the general subject of healthcare.

As he writes in his campaign biography, "A Charge to Keep," Bush "campaigned [in 1994] on a platform of four major areas: welfare, juvenile justice, tort laws, and education."

Healthcare was not among these, despite Texas' historically poor rankings.

But when asked about the subject on ABC's "This Week with Sam and Cokie" last Sunday, Bush spokeswoman Karen Hughes pointed out that "for seven years, [Vice President Al Gore has] failed to get a patients' bill of rights. And while [Gore] wants to talk about fighting ... Gov. Bush signed the strongest patient protection laws in the country right here in Texas."

Interestingly, according to Families USA, a nonpartisan nonprofit that works for affordable healthcare, both Hughes and the Gore advisor are correct. Texas' record on healthcare is mixed. It is, indeed, one of the best states in the nation when it comes to patient protections, but one of the worst when it comes to the sheer number of residents who are uninsured.

Ron Pollack, executive director of Families USA, cautions that "the governor's involvement in these two issues is not necessarily synonymous with where Texas has ended up on either of them. It's very important to distinguish" between what Bush heralds now and what his role was when the laws were getting passed.

On Bush's Web site, "The Texas Record" on healthcare comes down to four key bullet points, two of which are "Expanded Access to Health Insurance for Children" through "the Children's Health Insurance Program [CHIP] as well as an optional, parallel program for immigrant children" and that Texas "led the nation in patient and provider protections with health insurance reforms."

It is the battles for these two provisions that say the most about Bush and healthcare -- both for better and for worse.

For a campaign that regularly slams Gore for his "adventures with the truth" Bush's claims about the CHIP program are more than a touch hypocritical. In fact, Bush spokesman Ari Fleischer's dis of Gore's new TV ad can be directly applied to Bush's healthcare record.

"It's notable that Al Gore feels compelled to run a spot that exaggerates his biography," Fleischer said. "He exaggerates the role he played in welfare reform, an issue where he stood on the sidelines while others did the work."

While Gore implies he played a key role in reforming welfare -- which by most accounts he did not -- Bush's critics accuse the governor of outright revisionism.

"The kindest thing I can say about Gov. Bush's purported record on healthcare is that he has a very creative memory," Families USA's Pollack says. "The things that he takes greatest credit for are the things that he opposed most vigorously."

Pollack refers specifically to Bush's heralding of the CHIP program on his Web site, which boasts that "Bush signed legislation to create the Children's Health Insurance Program as well as an optional, parallel program for immigrant children. These two programs will ensure that 423,000 Texas children will receive health insurance."

"This occurred despite George Bush, not because of George Bush," Pollack says.

In 1997, the CHIP program was introduced to help states provide health insurance for children whose families are sandwiched between making too much money to qualify for Medicaid while not being able to afford private health insurance. And in Texas, the eligibility standards for Medicaid are extremely low.

In Texas, for a three-person family, a parent is eligible for Medicaid only if the family's income for the year is lower than $4,728 -- less than half of what a minimum wage worker earns for a half-time, 20-hour workweek.

Thus, if your income exceeds one-third of the federal poverty level in Texas -- if you even work half time at minimum wage -- you're too wealthy to qualify as a parent for Medicaid. It is here where CHIP attempts to fill the gaps.

During Bush's tenure as governor, kids kept falling off these rolls and spilling into the ranks of the uninsured, which simply added to the burdens of an inept healthcare system where kids go unimmunized and parents treat emergency rooms like walk-in clinics.

According to the Census Bureau, from 1995-98, Texas tied for last in the nation when it came to the percentage of citizens who are uninsured -- 24.5 percent. But, I ask the lobbyist familiar with the Texas healthcare debate, doesn't Bush understand that this ends up costing the healthcare system more? "Even from a cost-benefit analysis, it's something that's just not in his comfort zone," the lobbyist says.

One reason so many Texas kids were slipping into the ranks of the uninsured was its inept implementation of Clinton's welfare reform measures, a not uncommon problem throughout the country.

But the numbers are staggering. Texas is second in the nation when it comes to the number of uninsured children -- 1.4 million. A great deal of this has to do with the continued influx of poor, Mexican immigrants into Texas. But Bush's tenure has hardly improved matters.

During Bush's tenure, it is easy to argue, Dr. Bush has violated the Hippocratic Oath -- "first, do no harm."

Of all the states, Texas had the largest drop in children's coverage: In 1996 there were 1,360,304 children covered by Medicaid in the state; by 1999 the number of kids in Medicaid and CHIP combined had dropped to 1,166,904. This is a reduction of 193,400, or 14.2 percent. No other state came close to either the number or percentage of that reduction. The closest were Ohio, percentage-wise, with a 7.3 percent drop off, and California, numerically, with 121,788 children losing coverage.

Despite the huge number of children eligible for CHIP because of Texas' comparatively stingy Medicaid qualification standards, however, Bush pushed to have CHIP recipients capped at 150 percent of the poverty level, while Democrats pushed to include those at 200 percent.

According to state Rep. Elliott Naishtat, the Democratic chairman of the Texas Legislature's Human Services Committee, there is a disconnect between presidential candidate Bush's promise to "leave no child behind" and this "major fight that he had with the Legislature" where he was specifically pushing to leave approximately 240,000 children behind, the number of kids who "wouldn't have been covered if the governor had won."

"And it's not as if Texas didn't have the money," Naishtat says. "We were looking at a $6.1 billion budget surplus, and we had $17.3 billion from the settlement with the tobacco industry. But he fought us and fought us ... The governor and his staff fought me and those of us pushing this legislation until the end of the session."

But Bush lost.

"Now he's taking credit for signing into law one of the strongest children's health insurance programs in the country, which is true," Naishtat says, "but he fought us all the way."

Bush spokesman Bartlett counters that his boss's stance was just part of the process of negotiation. "The bottom line is that Governor Bush and those lawmakers involved all knew going into session that there were a range of options on the table, and that we were all going to be putting forth different options.

"Everybody knew going into this that 150 percent was going to be our starting point," Bartlett says, "but the governor's office worked with the House and Senate to determine what impact different levels would have. And as Governor Bush worked with the Legislature, everybody came to the agreement that 200 percent was doable ... To take a snapshot in time of [Bush's stance during] the early part of the [legislative] session -- while you discount the bill-signing ceremony, and the fact that the governor signed the bill -- is taking it out of context."

Democratic state Sen. Gonzalo Barrientos disagrees. "Oh, baloney," Barrientos says. "I just get so tired of that spin. We beat him. And this whole thing about 'It was a negotiating point'? Hey -- you don't negotiate with children's lives. Period."

As for Bush's heralding of the parallel program for qualified legal immigrant children, which was folded into CHIP during the legislative battle, Democratic state Rep. Garnett Coleman, who offered the bill, says that he can't recall Gov. Bush taking a stance one way or another while Republicans in the state House tried to have his measure killed. "If it makes it sound like he took leadership on the issue, that is just inaccurate," Coleman says. "If anything he was passive-aggressive in opposing it."

Naishtat insists that Bush simply had a philosophical objection to these programs, one that could be seen in other legislative battles. Because of welfare reform miscommunication -- again, a very common occurrence throughout the United States -- when mothers lose their welfare assistance because they didn't comply with state rules, often their children are automatically, though erroneously, removed from the Medicaid lists, though a vast majority of the children are still eligible.

To combat this, Naishtat introduced House bill 820, "which basically said that when a mom goes off welfare, the state must automatically review the eligibility of children for Medicaid to see if the kid's still eligible. If the child is, then the state's department of human services has to continue the enrollment of the kids in Medicaid."

Naishtat says that this bill, too, which merely attempted to keep the designation of already Medicaid-eligible children, met with Bush opposition. "The governor and his staff fought me and those of us pushing this legislation until the end of the session," he says. "Bush's legislative director, Terrell Smith, said they were concerned about the cost."

This was especially curious to Naishtat since Bush's first action in the 1999 legislative session was to declare a "legislative emergency" for the owners of oil and gas wells, bankrolling $45 million in severance tax relief for them -- a provision that met with overwhelming support in the Texas Legislature.

"In the end, we passed it [House bill 820] and he did sign it into law," Naishtat says. "But 'leave no child behind'? He did everything he could to leave these low income children behind."

For Barrientos, this is all part of a disturbing trend in Bush's presidential run, wherein the GOP nominee is stealing credit for bills he had nothing to do with -- literally nothing, no expression of support, no lobbying, no position -- until he signed them. During the Republican Convention, Barrientos was stunned when Gen. Colin Powell heralded Bush's support for Texas' "10 percent" bill, which opens college doors for the top 10 percent of students in every high school senior class.

"I was the Senate sponsor of the '10 percent' bill," Barrientos says. "I developed that plan with the help of some university professors. And I passed it through the Senate. He never called me, he never wrote about it, he never had any press conferences to testify about the bill. So for him to take credit for it like it was his idea, that's just not right. I'm not bashing Texas, I'm not bashing Bush. I'm just saying, 'Hey, folks -- here are the facts.'"

But the Texas healthcare battle that reveals most about Bush's leadership isn't necessarily the CHIP fight, where he now takes credit for the achievements of others. It's the patients protection act -- a muddled mess of politics, accomplishment, good intentions and confusing motives.

In 1995, state Sen. Jim Turner, a Democrat, and state Rep. John Smithee, a Republican, introduced an omnibus patient protection act.

"There was a lot of good of stuff in there," says Republican state Sen. David Sibley, an oral and maxillofacial surgeon. HMOs would be subject to the judgment of a prudent citizen, for instance, when it came to whether they'd have to pay for emergency room care, even at a hospital outside the HMO network. HMOs were required to disclose more, not only to enrollees in terms of the coverage provisions in each plans, but also to excluded healthcare providers specific reasons why they were cut out.

"The legislation had a great name," Bush writes in "A Charge to Keep." "The Patient Protection Act. How noble. How sound. How difficult to veto. How could anyone possibly be against protecting patients? ... What bad Governor could possibly veto a bill protecting patients, especially from unfair and unscrupulous HMOs? Of course, there was a lot more to it than that, but I knew that was what the critics would say."

Close observers say that Bush's attitude toward the bill was, in large part, annoyance. Healthcare wasn't one of the four priorities he'd just been elected to tackle, and the complexities of the issue were not on his presidential program.

"He didn't want to have to deal with it in his first term," says the Bush-supporting longtime Texas political operative. The bill was bipartisan, but "Bush's staff made it partisan ... It's a complicated issue, and he really doesn't like getting into these kinds of things. So they were uniformly hostile. There was a lot of trash talk in the back rooms."

On June 16, 1995, Bush vetoed the bill, and was vilified in the press. Bush has tried to market this as an example of his political courage, even at the time suggesting "Bush shows political courage" to newspaper headline writers.

But why Bush vetoed the bill is subject to considerable debate. According to Bush's veto proclamation, he was concerned about provisions in the bill that established two separate classes of HMO, since two health plans aligned with teaching hospitals -- Kaiser and Scott & White -- were exempted from the rules. Additionally, Bush's insurance commissioner -- Elton Bomer, a conservative Democrat who supported Bush during his race against then-Gov. Ann Richards -- argued that provisions that allowed patients to chose their own doctors would drive costs up.

Others see the issue more skeptically. Turner, now a congressman, says that "There's no question that from the beginning of this debate in Texas, the insurance industry was strongly opposed to the bill. Early on in the legislative process, the insurance industry had some members [of the Legislature] who expressed concern about certain things, and we worked with them." But in the end, the bill drew overwhelming support from the Legislature and, according to Turner, "I guess they [the insurance industry] realized they had one more place where they could kill the legislation. And that was the governor's office, after the session was over."

A specific insurance company founder was also discussed, by Charles Lewis of the Center for Public Integrity, who noted that Richard Rainwater, founder and then-owner of Columbia/HCA, the nation's largest for-profit hospital chain, strongly opposed the 1995 bill.

Rainwater, of course, is the man who orchestrated the sale of the Texas Rangers, in which Bush served as a partner, garnering him $16 million on a $600,000 investment. Rainwater has given Bush hundreds of thousands of dollars for his various campaigns, and Bush policies have gone on to reciprocate the love. As pointed out by the Dallas Morning News, for instance, the greatest beneficiary of Bush's "emergency" tax relief effort for oil and gas producers was the cool mil scored by Pioneer Natural Resources -- in which Rainwater is the largest single individual stockholder.

But then-insurance commissioner Bomer says that Bush "talked to me at length about" the patient protection act before he vetoed the bill, and neither Rainwater nor the insurance industry in general were part of the decision. In fact, says Bomer, now Texas secretary of state, Bush "wanted to see what we could preserve in the bill" by having Bomer issue regulations that would codify Bush's favorite provisions of the bill -- disclosure of HMO information to enrollees, HMO "report card" evaluations, the prohibition of HMO retaliation against patients for filing complaints.

"We preserved most of the bill, and the rules were enacted within a very few months," Bomer says. "And to somebody's credit, it's become a pretty good model for the country to look at."

Almost every player in the Texas healthcare wars gives Bush props for urging Bomer to enact these reforms. It is one of the few items they all seem to agree on.

Deluged with angry letters from the medical community after his veto -- "Dear George, Fuck you. You screwed up Texas medicine," one president of a county medical society reportedly wrote to the governor -- the Bush team thought that Bomer's regulations would have been enough. But Republican legislators like Sibley and Smithee, as well as the powerful Texas Medical Association, had other ideas.

"The more critical issues, like the right to hold an HMO accountable -- the right of a patient to go to court -- weren't in" Bomer's regulations, says Turner.

In the 1997 legislative session, Sibley and others broke up the 1995 legislation into several parts, filing around half a dozen bills, including one giving the right to sue an HMO if its decisions have harmed a patient's health -- the most controversial provision of any "patients bill of rights" bill.

Sibley, a Republican who wants Bush to be elected, says Bush "helped draft" the less controversial bills in the 1997 session: the codification of Bomer's regulations into law, the right of a woman patient to have her obstetrician-gynecologist serve as her primary care physician, and so on.

While Families USA's Pollack says that Bomer's regulations were "helpful," he points to the first patient protection bill to come up in the 1997 session -- Sibley's right-to-sue provision -- as the key one. "The things that [Bush] was more supportive of were the ones that are least controversial; the one that really provided accountability was the one that he opposed." The other bills that Bush signed without objection were, Pollack says, "what we call 'Gimme legislation.'"

Sibley says that he and Bush "talked a long time" about the right-to-sue bill. "It was a bill that's quite similar to one that had just been vetoed by [then-Florida Gov.] Lawton Chiles," who'd defeated Bush's younger brother Jeb in the 1994 governor's race.

"He said, 'Why am I gonna let this become law when a Democrat vetoed it in Florida?'" Sibley says. To assuage Bush's concern about an explosion of junk lawsuits against HMOs, Sibley says, a provision was added in the bill establishing an independent review organization made up of physicians that would assess the validity of complaints against HMOs before any would hit the courts. Still, it was unclear what Bush would do when and if the bill reached his desk.

It passed the Senate overwhelmingly, 28-3. Bush had been told that the vote on right-to-sue would be close in the house, but it wasn't, scoring a four-fifths majority.

There's a joke in the Texas House of Representatives: Whenever legislators get defeated by more than 100 votes it's called the "century club," and it means you didn't do your homework. When the right-to-sue provision hit 100, representatives started making bomb-whistling sounds. A weaker, Bush-backed alternate proposal was defeated 121-20.

"It was humiliating," says one witness.

Revisionism and election year politics aside, it's questionable how much Bush was indeed willing to work with the Republican lawmakers urging him to pass the right-to-sue provision.

For all Sibley's talk today about how wonderful Bush was during the May 1997 healthcare debate, different sentiments were coming from the oral surgeon's mouth at the time, as the Senate took up final passage.

Calling a personal privilege order on the floor of the state Senate on May 10, Sibley complained that a Bush "staff member" -- clearly a reference to Bush legislative aide Vance McMahan -- was pushing against the right-to-sue bill.

"The reason why all this is happening though is because I can't make somebody, some staff member in the governor's office, happy, and I can't make 'em happy no matter what I do unless I completely gut the bill ..."

Conservative Republican state Sen. Chris Harris, who also served on the healthcare task force that held hearings throughout 1996, then asked Sibley if "at every juncture on this bill, do you feel that we -- when I say 'we,' I refer to those of us that were on the interim committee that traveled the state -- have been stymied by the governor's staff?"

"I want to measure my words," Sibley said. "You know, as I have talked with the governor on this, I really believe that he understands the principle that underlies this ... But ... the person on his staff I've tried to work with, Senator, I am convinced there is nothing I can do ... to make 'em happy. The approach that he preferred went down in the House, it got 20 votes total ..."

Harris jumped back in. "So, if I'm understanding you correctly, here it is something that ... went down by 121 votes in the House ... passed by 28 votes in the Senate, and the governor's staff still will not listen, they still insist on, in essence, their way or no way ...?"

On this, Sibley demurred. And though Sibley blamed McMahan for the ugliness, Bush spokeswoman Karen Hughes confirmed that McMahan was merely carrying out Bush's orders.

The final bill passed. Faced with more ugly press and perhaps a veto-proof majority -- or at least a loser of an issue for Republican legislators -- Bush opted not to veto the key provision in the 1997 patient protection act, the right to sue. But as a way of voicing his concern, it became law without Bush's signature.

"I am concerned that this legislation has the potential to drive up healthcare costs and increase the number of lawsuits," Bush said. But, he added, "given the choice between doing nothing and doing something to address a significant problem that impacts the health of thousands of Texans, I have concluded the potential for good outweighs the potential for harm in Senate bill 386."

And though Hughes said that Bush was concerned about opening "a Pandora's box of lawsuits," since the time that the right to sue became law -- Sept. 1, 1997 -- Sibley reports that only five lawsuits against HMOs have been filed.

What will this mean for the country if Bush is elected? Though the Texas patient protection laws are similar to the Patients Bill of Rights law offered by Republican Rep. Charlie Norwood of Georgia, and Democrat John Dingell of Michigan, Bush says that he backs the more limited bill of rights laws preferred by the Republican leadership.

Bush's position is odd, since he and his aides laud a much bolder plan -- some parts of which he helped promote, others he tried to defeat.

On the campaign trail, politicians are afforded chances to help individual citizens. During Bush's South Carolina campaign swing in February, he was asked about government assistance to disabled students by Christine Green, a legally blind biology student at Coastal Carolina University. Told that neither the school nor her insurance could afford to buy her a device that would enable her to use a microscope, Bush opened the floor to bids for the $400 Green needed. A congressional candidate offered to pay.

"I'm very appreciative that he got the money for me," Green noted to an Associated Press reporter. "But I'm not the only disabled person in the world."

Conversely, when Gore was presented with the story of Ian Malone, a disabled child whose HMO denied him coverage, the vice president turned Malone into a cause célèbre. While critics slammed Gore for exploiting Malone's story for political gain, Gore slammed the HMO, fit Malone's story into a larger societal ill -- evil HMOs! -- invited the Malone family to the Democratic National Convention and mentioned them in his speech as a family for whom he would fight for "a real, enforceable Patients' Bill of Rights!"

It is reminiscent of the distinctly disengaged impression that Bush left CNN viewers with in March, when he was asked by reporter Candy Crowley about healthcare for the low-income single mother he talks about when discussing tax cuts.

"See, she doesn't have health insurance," Bush said. "She's got accessibility, in my state at least, to healthcare in emergency rooms and clinics, which isn't the most affordable and the smartest way to run a health system, I readily concede ... We're expanding CHIPs here, which is the Children's Health Insurance Programs, for children whose families in 200 percent of poverty and below.

"I'm going to be talking about the uninsured, the working uninsured," Bush said. "I'm going to talk about affordability, to work with states to devise plans where the premiums aren't out of the reach for the working uninsured. Allow small business, often times this person is employed by a small business that has trouble affording healthcare, and allow small business, small business associations, to write a plan across their membership so as to reduce the cost of healthcare for, the premium cost to be able to have affordable healthcare for her. I absolutely am going to talk about it."

And if Gore's lucky, voters will be listening.

Jake Tapper

Jake Tapper is the senior White House correspondent for ABC News.

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