On the morning of the final presidential debate of 1996, the top-of-Page 1 headlines and news stories in The San Diego Union-Tribune were on affirmative action, presidential ethics and the "crossroads" in the medical system.
During the Wednesday night debate, the nation heard a great deal from President Clinton and Republican challenger Bob Dole on the first topic and from Dole on the second. It heard much less from them on the final one, which likely will have the largest direct impact on the people of this area and the nation. Despite two well-phrased questions about the subject, Clinton offered few solutions that measure up to the scope of the problem -- and Dole virtually none.
The story in the local paper reported that a giant Tennessee-based, for-profit hospital chain called Columbia/HCA Healthcare Corp. was poised to take control of "about 40 percent of the region's medical care" by buying out one local, nonprofit group with six hospitals and by taking over management of two medical centers now run by the University of California-San Diego.
The story by reporter Rex Dalton raised questions of how "the fragile safety net for medical indigents" will be affected if control of the major hospitals shifts "from community leaders to a large corporation beholden to shareholders."
If this were an isolated phenomenon, it might be of concern only to people on this sunny coast. But comparable developments are taking place across the country, including my hometown of Arlington, Va., where the community hospital is joining the very same health care corporation. Since the collapse of the Clinton health care plan in 1994, a vast consolidation has been taking place in the private marketplace, raising the question of how consumer interests will be protected from these medical trusts.
When a health care worker raised these problems at the Wednesday night town-meeting debate here, Clinton said he favored federal legislation to prevent managed care companies from imposing a "gag rule" on doctors that would deny patients information about more effective, but more expensive, treatments.
Dole said that fee-for-service medicine must not be eliminated, but did not explain how the family doctor was to be preserved. As for managed care, he said, "You're going to have to watch it." Thanks a lot.
The problems of the insured are one thing, but there is also a growing problem of people without insurance -- an issue the candidates are reluctant to face.
The American Hospital Association recently released a study it commissioned on this issue. Based on the trends in the last seven years, which saw the number of uninsured grow from 30.6 million in 1988 to 39.6 million in 1995, the Lewin Group Inc. estimated that 45.5 million people will be uninsured by the time the next president takes office in 2001.
When the insurance question is raised, both Clinton and Dole have claimed credit for the Kennedy-Kassebaum bill, which passed Congress this year and which would guarantee portability of health insurance to people changing jobs.
But the Lewin study notes that "the impact of this legislation is likely to be small since 45 states had already enacted similar legislation by 1995." Any gains it brings, the study said, will be more than offset by employers dumping retirees and dependents from plans and requiring workers to pay higher deductibles and co-payments.
On all of these matters, the candidates are largely silent. They endorsed a bipartisan commission -- a convenient dodge -- to wrestle with the looming bankruptcy of Medicare. And when moderator Jim Lehrer asked them directly at the first debate in Hartford, "What do you think should be done about the health care system?" they went back to talking about the Kennedy-Kassebaum bill and the wonders it is supposed to perform.
Clinton said here that he'd like to see another million youngsters added to the Medicaid rolls. Dole had made a similar suggestion in Hartford, saying that "there are a lot of uninsured people in this country, particularly children, that should be covered" and suggesting that one way to do it was to "expand Medicaid." The Republican budget, of course, projected large-scale savings in Medicaid and returning the program to the states.
Dole also told the Hartford audience, "In America, no one will go without health care."
Pick up the paper, candidates, and smell the coffee. The real world says otherwise.