WASHINGTON -- In the cramped confines of a family-owned pharmacy, Pauline Armes hobbled toward Vice President Al Gore, jangling a plastic bag filled with $300 worth of medication: arthritis pills, back-pain pills, blood pressure pills.
Living on a $682 monthly fixed income, the 76-year-old retiree from Suitland said her prescriptions have virtually exhausted her savings. By the new year, she will no longer be able to afford the $1,600 a year for her Medigap insurance and will have to join a managed care plan she does not trust to deliver the care she needs.
"Health care needs help," Armes said. But politicians, "to me, they're not trying too hard."
Monday's news media event was arranged by the vice president, who is eager to appear sympathetic to the plight of Americans struggling to find affordable health care. Five years after the failure of President Clinton's health care plan appeared to banish such bold proposals from the political stage, access to affordable care has re-emerged as a high-profile issue.
In the contest for the Democratic nomination, Gore and former Sen. Bill Bradley have trumpeted their health care proposals while criticizing each other's. Republican candidates have been largely silent on the issue, but they are facing pressure from voters to proffer their own plans.
"I thought that the Clinton effort was going to poison the well for a lot longer," said Alain Enthoven, a Stanford University health-care economist who helped open the debate in 1992. "But on the other hand, it is a very important problem."
The problem is growing, Enthoven said. The ranks of the uninsured grew by 1 million last year, reaching 44.3 million. Disenchantment with managed-care insurance plans continues to grow.
Senior citizens are becoming increasingly concerned about the rising costs of prescription drugs, which are not covered by traditional Medicare. In Washington, proposals to address these problems have become embroiled in partisan politics.
"I hope that it'll be a huge issue in the campaign, and I feel that it will be," Gore said. "It must be central."
Gore's three-issue attack
Gore has proposed attacking the nation's health care problems as three issues: helping the elderly by including a prescription drug benefit in Medicare; reassuring managed-care patients by securing a broad "patients' bill of rights"; and aiding the uninsured by expanding eligibility for a program that was established two years ago for children in households too affluent to qualify for Medicaid but too poor to afford private insurance.
The Gore plan would also allow low-income parents to enroll in the program and those as young as 55 to buy into Medicare.
Bradley's $650 billion plan
Bradley, a former New Jersey senator, has proposed a more comprehensive plan that is intended to guarantee health insurance for all children while providing access to affordable health care for everyone through tax credits and government subsidies.
Under the Bradley plan, low-income Americans would receive subsidies of $1,800 a year to buy insurance plans now offered only to federal employees. Parents would be required to insure their children. And all Americans would receive tax credits to offset the cost of insurance premiums.
Bradley would also add a prescription drug benefit to Medicare. In addition, he would eliminate Medicaid, the 34-year-old program for the poor, and move Medicaid recipients into the insurance market with federal vouchers.
Bradley estimates that his plan would cost up to $650 billion over 10 years. Others estimate it would cost considerably more.
First substantive debate
The conflicting proposals have created the first substantive debate of the presidential campaign. Gore has attacked Bradley's plan as a budget-buster that would squander the federal budget surplus while doing nothing to extend the solvency of Medicare.
Bradley has accused Gore of timidity. He argues that the vice president turned his back on the Clinton administration's health care goals, abandoning "that fundamental Democratic principle of basic health care for all Americans."
Many health-care activists say neither plan is sufficient, but they are heartened that the issue has been revived. The collapse of the Clinton administration's health-care initiative helped Republicans win control of Congress in 1994 and had Democrats shying away from huge spending programs.
Clinton soon declared that "the era of big government is over."
"We didn't have any illusions about how easy it would be to bring back health care to the national agenda," said Rachel DeGolia, associate director of the Universal Health Care Action Network, which pushed the issue in 1992 and is trying again this year.
Lacks same weight
The resurfacing of health care during the Democratic primary campaign does not mean it carries the same power as when the plight of the uninsured helped Clinton to office in 1992, said Robert Blendon of the Harvard University School of Public Health.
Seven years ago, the nation was mired in recession. There were fewer uninsured than now, but amid economic anxiety, the crisis hit home with workers who feared they might soon join the ranks of the uninsured.
"You don't have that sense of urgency now," Blendon said.
Instead, he said, fears about health care arise among three groups that might not think their interests coincide: the elderly, the uninsured and those angry at HMO control over health care decisions. Gore has opted to appeal to each group.
Bradley's comprehensive plan has struck a chord with core Democratic voters, who tend to be senior citizens or low-income workers less likely to have affordable health care. It has been praised by health-policy experts from the left and the right.
Moderate, higher-income swing voters might blanch at the costs and be more attracted to Gore's incremental approach, Blendon said.
GOP candidates 'steer clear'
Republican candidates have stood on the sidelines as the Democrats have battled it out. Republican campaign aides concede that health care issues -- especially concerns about managed care -- arise constantly at town hall meetings and campaign events. And most of the candidates have posted health care proposals on their Web sites, with varying amounts of detail.
But none of the Republican candidates has made the issue a central theme. At a recent debate in New Hampshire, conservative social activist Gary L. Bauer launched a broadside against managed care, endorsing the Democrats' demand for a right to sue HMOs for denying care. The other candidates remained silent on the issue.
"Republicans won't [engage in the debate]. They can't," said Dave Durenberger, a former Republican senator from Minnesota who lobbies for long-term health coverage. "The first thing they're told is: 'Don't debate health issues. The Democrats will clobber you.' So they steer clear."
'World is changing'
That strategy will work during the primary season, said GOP pollster Ed Goeas, but the Republican nominee will eventually have to engage in the health care debate in the general election. Health care concerns were the leading priority of 6 percent of Republican voters in a recent poll, Goeas said, putting the issue well behind declining moral values, education, crime and drugs, Social Security and tax cuts.
Among Democrats and independent voters, health care hovers at or near the top of the list. Even among Republicans, "6 percent on an open-ended question is still a good response," Goeas said.
Linda DiVall, another Republican pollster, agreed that her party's nominee will not be able to fall back on the old strategy of shifting the debate from a traditionally Democratic issue, such as health care, to turf that is more amenable to Republicans.
"In the general election, health care is an issue that will have to be addressed," she said. "The world is changing. The past issue message of taxes, welfare, communism and the Cold War is no longer relevant."