The presidential candidates and long-term care.

Four months before the first real presidential nomination caucuses, polls generally agree that the leading candidates among the Democrats are Sen. Hillary Clinton of New York, former Sen. John Edwards of North Carolina, and Sen. Barack Obama of Illinois. On the Republican side, the leading candidates for nomination appear to be former New York City Mayor Rudy Guiliani, former Gov. Mike Huckabee of Arkansas, Sen. John McCain of Arizona, former Gov. Mitt Romney of Massachusetts, and former Sen. Fred Thompson of Tennessee.

Compared with previous recent presidential elections, this is a surprising list of front-runners, for several reasons:

* Lack of proven (re)electability. Of the three leading Democratic candidates, only Clinton has stood for reelection to a federal office. On the GOP side, Romney chose to serve only one term, although his rivals did win reelection to some office.

* Lack of lengthy exposure to the public. Where were these front-runners 10 years ago? Clinton, of course, was the spouse of the president of the United States, McCain was an ex-naval aviator with years of experience in the Senate, and Guiliani, a Reagan appointee in the Department of Justice, was mayor of America's largest city. The other candidates, however, were far more obscure. Thompson and Huckabee were newly in office, Edwards was a defense attorney in private practice, Romney was the CEO of Boston-based Bain Capital, and Obama was serving the first year of his term in the Illinois state legislature.

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* Ethnic and religious diversity. In this lineup, Thompson stands out as uniquely typical of past U.S. presidential candidates. The front-runners include a woman, a former Baptist minister, two Roman Catholics, the Hawaiian-born son of an African immigrant, and a member of The Church of Jesus Christ of Latter-day Saints. Clearly, this is not your grandfather's presidential campaign.

Voters concerned about the uncontrolled costs of providing healthcare to the American people will also find the presidential contenders unusual in their lack of accomplishment in the health and human services arena--with one obvious exception. Most of them have sat on the health policy sidelines in an era marked by major changes to Medicare and Medicaid, widespread state experimentation in healthcare financing, and growing debate on how to provide long-term care to the aging baby boom.

Speaking to a recent meeting of healthcare providers in Rochester, New York, the obvious exception, Clinton, reminded her audience that "I've done a little work on health care myself, and still have the scars to show for it," adding, "[a]nd in the twelve years since, the problems confronting our system have only grown. Costs have continued to rise, the ranks of the uninsured have increased, and strains on our system and its ability to provide quality care have worsened." (Some harsher critics contend she has, in part, herself to blame, having overseen creation of a healthcare reform plan laid out in such lengthy and confusing format that it was easily trashed by political opponents, thus setting back the cause by at least 10 years.)

Romney, like Clinton, has a mixed record in healthcare policy. Although he takes credit for the "universal care" enacted by Massachusetts under his administration, the initiative for the state program came from the legislature rather than his office. In fact, much of the healthcare financing plan was passed despite his threat to veto major components. More recently, he has stated his opposition to the enactment of a Massachusetts-style reform on a national scale.

On the other hand, several of the initiatives that Romney actually sponsored were aimed at cutting reimbursements to SNFs or preventing low-income elderly from qualifying for Medicaid. In 2003, for example, he sought a Medicaid waiver establishing more stringent rules against adults who make gifts to their children and later need MassHealth (Medicaid) to pay for nursing home care. Specifically, instead of disallowing Medicaid enrollment for a specific time after the provision of a gift, Romney's waiver proposal began the penalty period with the date of application to enroll in Medicaid. One commentator stated, "The Governor's plan is to penalize everyone for making gifts five and even ten years ago because he thinks the only reason you did it was so that you would become eligible for Medicaid."

McCain has limited his healthcare focus throughout his Senate career to veterans' healthcare and, although New York City is one of the few municipalities to operate its own network of nursing homes, Guiliani conducted limited oversight over the city's Health and Hospital Corporation. None of the other Republican candidates have a significant record in launching healthcare programs or financing proposals.

Clinton currently is a cosponsor of bipartisan legislation that provides tax credits for Americans who purchase long-term care insurance, and she made minor contributions to the Nurse Reinvestment Act. Most of her proposals on healthcare, however, have never been enacted. Similarly, while Edwards has recently advocated insurance coverage for all Americans, he is far better known as an expert litigator in arguing medical malpractice cases against clinicians, insurance companies, and facilities, rather than as an innovator in healthcare policy. Obama's approach to healthcare as a legislator has been to try to force federal departments to spend money on researching specific therapies or health conditions that have piqued his interest; in most cases, these efforts have not attracted support from his fellow Democrats.

Surprisingly, two of the early dropouts from the presidential sweepstakes had very impressive records in pursuing healthcare policy. Iowa Governor Tom Vilsack had devoted much of his two terms to restoring financial solvency to Iowa's state healthcare system and improving coordination among healthcare providers. Vilsack withdrew from the Democratic nomination effort this spring, however, after receiving lots of jokes from late-night TV comedians about the obscurity of his state and his Slavic name, but almost no financial contributions. Wisconsin's Tommy Thompson had enacted the model of welfare reform during his several terms as governor and pioneered nursing home quality improvement efforts in collaboration with the long-term care industry during his four years as President George W. Bush's Secretary of Health and Human Services. Thompson took his name out of contention for the Republican presidential nomination after finishing sixth in an Iowa straw poll in August.

The withdrawal of these candidates who actually walked the walk of healthcare reform is probably no coincidence. Healthcare policy is easy to talk about but hard to enact or sell to the American people. The political leaders who have strong records in actually accomplishing work on healthcare--and especially on long-term care--tend to be serious, studious, and practical; in other words, they are policy wonks. Tommy Thompson tried hard to make points with the Republican voters in Iowa by talking about his leadership on the Pandemic Influenza Response and Preparedness Plan and his advocacy as chairman of The Global Fund to Fight AIDS, Tuberculosis and Malaria. They didn't care; it was no match for the glamour offered by Republican candidates who framed their untried solutions in soul-stirring sound bites. Similarly, Vilsack was penalized because he took time trying to explain his accomplishments in the healthcare field while his rivals were attracting hard-core Democratic donors with ideas and proposals that have not been enacted or tested politically.

In the 18th century, advocates of the creation of an office of president of the United States wrote the Federalist Papers in part to reassure the American people that schemers and celebrity-seekers would not be elected. "Talents for low intrigue, and the little arts of popularity, may alone suffice to elevate a man to the [highest] honors in a single State," they wrote, "but it will require other talents, and a different kind of merit, to establish him in the esteem and confidence of the whole Union...." In the context of healthcare policy, it would be fascinating to know what those Founding Fathers would think of the current crop of presidential front-runners.

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