The search for responsible health care

The push to provide prescription-drug benefits for America's senior citizens has been under way for several years. One reason it is taking so long to come up with a plan is that the most ideal proposals are the least affordable.

Debate over government-subsidized prescription benefits for the elderly was renewed when President Bush announced, as part of his State of the Union address, his plan to spend $400 billion over the next 10 years to revamp Medicare -- primarily to pay for the prescription-drug benefits.

The president's plan has raised questions among Republicans and Democrats alike in Congress. The president wants a managed prescription-drug program, while most federal legislators want drug coverage for all senior citizens, not just those who opt for managed care.

The complication, of course, is that managed care would presumably be less costly to the federal government than universal coverage. And the federal government is already dealing with an example of what happens when limited coverage suddenly becomes universal.

The VA lesson

Look at the Veteran Affairs health-care system. The VA's traditional role has been treating veterans with service-connected injuries and disabilities. In 1996, Congress ordered the VA to open its health system to nearly all veterans. As a result, the number of VA patients has swelled to 6.8 million from 2.9 million.

On the one hand, nearly 4 million more veterans have had access to the benefits of the VA system's inexpensive care and prescription-drug program. But the downside is that the crush of the additional patient load is about to break the VA system. It can't recruit enough doctors and nurses, It makes some veterans wait months for appointments and medical procedures. And now there is good cause to worry that a war with Iraq would increase the VA patient load considerably.

Then there's the cost of providing medical care for 4 million more veterans. The 2003 budget calls for spending nearly $24 billion on the VA health system -- which U.S. Rep. Christopher Smith of New Jersey says will be $2 billion short of what's needed to cover costs.

There is strong emotional support for helping veterans, and many of those same heart-felt arguments can be made for the nation's elderly. The question -- as with most things governmental -- is how to pay for expanded health-care services and prescription-drug programs.

Last week, the Bush administration suggested a way to raise $2 billion. including increased enrollment fees for some higher-income veterans who want VA health benefits.

Fees and controls

The Bush budget planners are not too far off the mark in suggesting user fees and other methods to help control costs and limit participation to those who really need the services offered by the VA health system or who really need help with prescription drugs.

The problem with universal coverage is that those who can afford to pay for medical services out of their own pockets get the same benefits as those who are strapped for money. Moreover, adding millions of participants who can afford to pay their own medical costs to any government-backed program only clogs the system, as with the VA system, and makes it even more difficult for those who have no other recourse to receive needed and often life-saving attention.

Opponents of the Bush prescription-drug plan say it would force elderly participants to give up fee-for-service coverage -- which allows senior citizens to pick their own doctors -- and enroll in managed-care programs. HMO has become a dirty word, but the fault lies with management abuses, not with the overarching goal of controlling costs while delivering services that are truly needed.

Without some system of making sure government-backed programs are delivered to the needy, there is little chance Congress will ever agree on health subsidies that are affordable. It would make sense for congressional architects of prescription coverage and veterans' benefits to listen to ideas that include enrollment fees, oversight of services and limited accessibility for those who need help the most.

Private employers know well what has happened to health-care plans for their employees. Some companies have dropped their health plans entirely. Others are looking for ways to continue coverage with more financial responsibility placed on employees.

Give the mushrooming costs of medical care, proponents of government-backed health systems must look for ways to turn beneficiaries of these programs into responsible consumers.