John Kerry: absent on healthcare?

Before the spring primary season (at the time of this writing), Sen. John Kerry of Massachusetts appeared to be the likely Democratic presidential nominee. If that bears out, now is the time to get some bearing on his thinking about healthcare--and perhaps even (dare I say it?) long-term care.

Over the past several months, we have learned much about Kerry. He is a war hero and a former criminal prosecutor. He enjoys a gift for phrases, describing his issue positions as "The Real Deal" and scoring rhetorical points in the Democratic presidential primary debates.

Kerry presents a less impressive image, however, in the health policy field. For an individual who has served in the U.S. Senate since 1985, Kerry has displayed unusually little interest in the big issues of health policy. He rarely even signs on as a cosponsor of his senatorial colleagues' health-related bills.

Not surprisingly, Kerry's "Real Deal" for healthcare, announced at Mercy Hospital in Iowa last year, appears as a disjointed assembly of individual proposals. The centerpiece is federal government coverage of 75% of expenses for acute-care episodes that cost more than $50,000. In effect, if a person's costs associated with a heart attack total $60,000 in hospital and physician charges, the federal government would pay $45,000 and the private insurer $15,000.

Kerry's proposal makes the federal government serve as payer of catastrophic healthcare costs only for "companies that provide affordable coverage for all their workers, guarantee they'll pass back the savings to their employees, and put in place preventive care and health promotion programs." People who pay for their own insurance apparently would not be eligible for this catastrophic coverage. Assuming that insurance companies pass on their healthcare coverage savings to all of their customers, Kerry estimates that "we will reduce average premiums by up to 10%."

Kerry's healthcare proposals provide tax credits for small businesses that purchase healthcare benefits for their employees and a federal "technology incentive bonus" to help hospitals pay for upfront technology costs. Kerry also offers hospitals "a quality bonus ... to adopt new forms of treatment that offer patients better care and save money in the long run."

Individual consumers are not ignored by Kerry's health plans: They become eligible to purchase the same health plan "that covers the President, the Vice-President, and the members of Congress." As he explained in Iowa:

  Nine million federal employees and their families now receive
  healthcare through a system that offers a wide choice of affordable
  coverage with group protections and good benefits--and it should be
  available to every American who wants it. Under my proposal, everyone
  from large employers to the self-employed or those that buy coverage
  as individuals will be able to join this system.

Specific categories of consumers would get additional federal benefits:

* Washington would pick up the full cost of Medicaid for eligible children under the age of 18, if the states agree to begin enrolling low-income youth and their parents in the shared-cost State Children's Health Insurance Program (SCHIP).

* The federal government will offer a health insurance tax credit to unemployed Americans and to retirees between the ages of 55 and 65.

Kerry also promises special assistance to "about 400,000 qualified veterans [who] are being denied access to VA healthcare, and more than 235,000 veterans already in the system ... waiting six months or more for their first doctor's visit."

One fundamental problem with this collection of healthcare reforms is that it relies heavily on the goodwill of the insurance industry to advance public policy. Aside from possibly sharing their "savings" in the form of reduced premiums, insurers would be responsible for certifying that their business customers are providing healthcare benefits and preventive care for all employees. Another assumption is that insurers and acure-care providers will ignore the financial benefits of ensuring that more cases exceed the $50,000 floor, shifting more of the cost to the federal government.

Kerry's "Real Deal" for healthcare also suffers from a classic form of Washington myopia: the inability to recognize anything other than a hospital as a healthcare provider. Kerry restricts many of his proposed benefits to hospitals; his health financing reforms are limited to acute care. His few references to nursing homes offer vague assurances that "seniors who live in nursing homes [will] receive quality care, with adequate inspections, reimbursements, and more training for healthcare workers." Similarly, Kerry's ideas on long-term care financing are limited to protecting Medicaid from proposals to transform the program into a block grant and allowing Medicaid to pay for more alternatives to nursing home care.

This rather paltry offering on long-term care is paradoxical in view of the fact that his single piece of healthcare-related legislation in recent years, the Nurse Reinvestment Act of 2001, had the potential to make a major difference for nursing home operations. When introducing the bill, Kerry specifically mentioned SNFs as being affected by the crisis in nursing personnel:

  We are in the midst of a serious nursing workforce shortage. Every
  type of community, urban, suburban, and rural, is touched by it. No
  sector of our healthcare system is immune to it. Across the country,
  hospitals, nursing homes, home healthcare agencles, and hospices are
  struggling to find nurses to care for their patients. Patients in
  search of care have been denied admission to facilities and told that
  there were "no beds" for them. Often there are beds, just not the
  nurses to care for the patients who would occupy them.

Kerry's Nurse Reinvestment Act proposed that states could receive an enhanced federal match of 90% for the costs of nurse education and training in nursing homes. In addition to educational benefits, the bill would have established a National Nurse Service Corps that would send qualified nurses to serve in communities across the country that are now turning away patients as a result of staff shortages.

The Nurse Reinvestment Act attracted 38 cosponsors in the Senate, and needed only 12 more senators to win majority support. But it never came up for a vote. It was assigned to the Senate Finance Committee whose chair, Sen. Charles Grassley (R-Iowa), refused to even pass it along for consideration by his subcommittee on health.

Perhaps the fate of the Nurse Reinvestment Act taught Kerry a lesson: Legislation benefiting long-term care providers might well be a political liability. Or perhaps the problem is that, having seen so many Democrats burned by advocacy of healthcare reform, Kerry has decided to abandon addressing the issue in any substantive way this year. In either case, while Sen. Kerry may yet win the nomination and even the presidency, the whole country loses yet another year of serious debate on a vital issue.

To comment on this article, please send e-mail to [e-mail].