CLEVELAND - It has been seven difficult years since Barbara Wulff's mother was stricken with Alzheimer's disease, seven years of searching for the right caregivers - and of paying prescription drug costs as high as $800 a month.
Wulff is not political, she said, certainly not a partisan of one party or another. But this election season, she is painfully aware of one issue that could decide her vote in November: the cost of her mother's medication.
"By the time we pay $4,000 a month for her care, another $800 for her medication, that's a serious chunk of change," sighed Wulff, a computer programmer from Uniontown, Ohio.
In a presidential election that once appeared bereft of a burning issue, the question of soaring drug prices for seniors has emerged front and center. Only a fraction of the 49 million people on Medicare completely lack coverage for prescriptions, but the power of the issue extends well beyond those 12 million seniors.
It has struck a chord among seniors who worry about the future of their insurance plans, and among millions of aging baby boomers who are caring for elderly parents and looking with trepidation toward their own retirement.
By 2002, the number of seniors with no drug coverage will likely rise from about a third to about 40 percent, as private insurers drop such coverage or leave Medicare altogether, according to the Congressional Budget Office.
And those who keep their drug coverage will likely pay higher deductibles or co-payments. The median drug bill for seniors is close to $100 a month, and rising by 15 percent a year, said John C. Rother, director of legislation and public policy at the American Association of Retired Persons.
"For people who are not well-insured, this is the No. 1 issue," Rother said, "an observation borne out by interviews with seniors in the suburbs of Cleveland and Akron.
Ohio will be a critical state on Election Day, especially for Gov. George W. Bush. No Republican has ever won the presidency without carrying Ohio, which was once solidly in Bush's camp but is now up for grabs.
Both Bush and Vice President Al Gore have proposals to expand prescription drug coverage. And both would spend considerable federal dollars: $338 billion over 10 years under the Gore plan, $148 billion under Bush's.
But for Bush, it may not be enough to simply present a proposal to an electorate inclined to trust Democrats on health-care issues. In many ways, Bush's plan to add a prescription drug benefit to Medicare by injecting more private competition is bolder than Gore's more conventional approach - and the one that holds out the prospect of a long-term fix for the beleaguered system.
But the Republican candidate must battle the perception among seniors that Gore's plan is more generous and less restrictive.
"I think [the Bush proposal] is fine," said a prominent Republican health-care consultant who spoke on condition of anonymity. "It's not gangbusters. It's not something that's going to completely neutralize the issue, but it's a step in the right direction. And it's going to take a lot more work. For a Republican on this kind of issue, it always does."
Seniors in the suburbs of Cleveland illustrate this problem. Even the most ardent Bush supporters do not know the essence of what the Texas governor is proposing.
Bush is "just throwing out sops to us oldsters," said Dave Wible, 84, a staunch Republican living in an upscale retirement community in Hudson, Ohio.
Seniors see Bush's plan as more selective in whom it will cover, more dependent on HMOs and less likely to offer choices.
"I don't want to be told what doctor I should go to," said Eunice Radike, 81, a lifelong Republican from Parma Heights who plans to vote for Gore. "With Bush's plan, it sounds like you're going to be told."
Bush does not have a plan so much as a "framework," suggested Charles N. Kahn III, president of the Health Insurance Association of America, which represents small insurance companies.
The Bush plan has two parts.
The first - block grants to the states totaling $48 billion - is intended to extend coverage to poor seniors as quickly as possible. States could offer drug coverage through Blue Cross, through an expansion of Medicaid or through their own programs.
Seniors who earn $11,300 or less, and couples with incomes of $15,200 or less, would have their drug bills completely paid by the government. But for those with higher incomes, the government would pay no more than 25 percent of the total drug bills.
This temporary plan would be replaced in 2005 with an overhaul of the entire Medicare system. Though the details must be worked out, Bush envisions private insurers competing for the 39 million seniors now in Medicare. Seniors could choose one of those private plans, or keep Medicare's existing fee-for-service coverage.
Gore would spend more than twice as much money and simply add an optional drug benefit to the existing Medicare program.
Seniors would pay a $25 monthly premium to join the voluntary program. In 2008, when the plan would be fully phased in, Medicare would pay half of drug costs up to $5,000 a year. Out-of-pocket expenses would be limited to $4,000 a year, after which the government would absorb all costs. Seniors who earn $11,300 or less - $15,200 for couples - would pay nothing.
Critics of Bush's plans worry about its heavy reliance on state governments and private insurance companies. Twenty-two states have, or are creating, government plans to help seniors with drug costs. For the 28 other states, including Bush's native Texas, converting block grants into prescription drugs could take years.
For his broader proposal to reform Medicare, Bush is banking on private insurers rushing to compete to offer health care, including prescription-drug coverage, to seniors. But history suggests that private insurers are not eager to provide such coverage.
Medicare was amended in 1997 to let HMOs compete for patients. While some HMOs have done so, their initial enthusiasm has clearly waned.
Sixty-five HMOs have said they will drop out of Medicare next year. Fifty-three others have reduced their service areas. In all, 934,000 seniors who joined HMOs, many of them enticed by prescription drug coverage, will be dropped in 2001.
"The trends are all in the negative direction," said Richard Sorian, a senior researcher at Georgetown University's Institute for Health Care Research and Policy. "Even seniors with coverage feel vulnerable, and they're spending more and more for it."
Bruce Vladeck, a former Clinton administration Medicare administrator, said many insurers are dropping out because they discovered they could not turn a profit unless the federal government steadily raised its reimbursements to them. Yet as critics note, the very reason the HMOs were invited into the system was to restrain escalating health care costs.
"The notion that this is a way to save money is contrary to all the evidence," Vladeck said.
But Gail Wilensky, another former Medicare chief who is Bush's top health care adviser, argued that the blame for the exodus lies with the Clinton administration, which she said has imposed too many requirements, such as quality-control reports. If insurers could operate under a new agency, as Bush has proposed, Wilensky said, "I think they'll come back."
Bush's insistence that seniors could remain in traditional fee-for-service Medicare might also keep too many seniors in that system, thereby erasing any savings his plan envisions. Under Bush's plan, Medicare would begin offering a prescription-drug option, just as Gore has proposed, Wilensky said.
For Bush to keep costs well below Gore's level, seniors would have to shift to managed care in droves. But since a managed-care option was added to Medicare in 1997, only 16 percent of seniors have opted to join an HMO.
Health care experts say they believe the Bush plan would raise premiums for the fee-for-service program so high that most seniors would have no choice but to try to switch to HMOs.
Gore's plan has its critics as well. Vladeck asserted that coverage would phase in too slowly. But the dominant criticism is that Gore would fail to reform a program that could be swamped by retiring baby boomers.
"At least [Bush] has taken the responsible step about being honest about a big problem," said Kahn, the Health Insurance Association president. "Gore hasn't."
Such issues sound distinctly remote to Radike, who has wrestled with colon cancer, a heart attack, quadruple bypass surgery, four eye operations, knee surgery and now vertigo.
Her mother was once president of the Republican Party's women's auxiliary in suburban Cleveland. Her family cherishes the badge her uncle wore as he marched in Theodore Roosevelt's inaugural parade.
"I was for Bush for quite awhile," she said. "But after hearing Gore's platform, I've decided he's a little more for the elderly than Bush, who was born with a silver spoon in his mouth."