Rep. Robert E. Wise Jr. (D-W.Va.) was surrounded by television cameras and a score of elderly voters as he stood inside a Charleston pharmacy last week, clasping a piece of political gold: a new study showing that Medicare patients in his district are charged more than twice as much for popular medicines as young people with good health insurance.
And like similar reports released lately by 54 other House Democrats before him, Wise's study did not disappoint. It produced a banner headline in the Charleston Gazette and fodder for talk radio across the state. So many constituents called for their own copy that when the congressman telephoned his district office, he was put on hold for two minutes.
"This is one of those cases where good policy and good politics are merging rapidly," said Wise, who plans to raise the issue as he campaigns for the West Virginia governorship next year.
The dozens of Democrats who have won glowing headlines by exposing inflated drug prices -- and the dozens more who are queued up, waiting for studies of their own districts to be completed -- reflect the party's gleeful discovery that the cost of prescription drugs is fertile political terrain. More fundamentally, the drug studies reflect the extent to which the issue of health care is back on stage, promising to figure in the 2000 elections more visibly than it has in years.
The renewed potency of this issue is evident to both parties. Already, health care is looming large as Democrats and Republicans joust for control of the House of Representatives, and almost all the presidential candidates either have staked out their stands or are preparing to join the debate.
"I think we're on the cusp of health care exploding as a major issue again," said Robert L. Laszewski, a Washington-based health policy consultant. "It's clear to me this freight train is coming down the track, and it's bigger now than it was in 1992."
If health care is back on stage, however, it is reprising in somewhat different form than when it burst forth seven years ago as a defining theme of Bill Clinton's first campaign for the White House. The differences this time involve how the parties are positioning themselves and how the issue is being defined.
In contrast with the broad mantle of "health reform" that some Democrats invoked earlier in the decade, politicians are now wrestling with a collection of distinct worries -- some of them remnants from the early 1990s, others more recent.
In addition to elderly patients' frustration with the price of medicine, issues include the public's eagerness for more clout with managed-care plans, fears that the vast Medicare health insurance system soon will become insolvent, anxiety about lapses in the confidentiality of medical records, and renewed concern about the escalating cost of health care and the number of Americans without health insurance.
"Each one of those has its own center of gravity rather than having one big comprehensive health care agenda," said Sen. Bill Frist (R-Tenn.), a former heart surgeon who is a leader on health issues in the Senate.
This fragmentation has occurred largely because the Clinton administration's failed attempt to overhaul the nation's entire health care system in 1993 and 1994 left behind an indelible lesson: Patients look toward Washington for help, but not too much help. "People want some of these issues addressed," said Robert J. Blendon, a health policy professor specializing in public opinion at the Harvard School of Public Health. "But there's no stomach for really big changes out there."
The second difference as the 2000 elections approach is the posture of Republicans. Unlike when the GOP scored a huge political victory by blocking the Clinton health plan, Republicans now are striving to be more than obstructionists. Mindful that voters have long tended to trust Democrats more on health matters, the GOP is offering counterproposals rather than outright opposition on issues ranging from Medicare to patients' rights. Republicans often are taking positions that involve a more limited federal role and greater reliance on the private medical marketplace.
"In '91, the Democrats had programs and we did not," said Deborah Steelman, a health care lobbyist who is advising the presidential campaign of Texas Gov. George W. Bush. "Now, it is becoming clear what Republicans are for."
Both the issue's fragmentation and the altered GOP position are evident in the health care questions now drawing the most attention in Washington. As the Senate is poised to begin a tempestuous debate on Monday over whether to restrict the powers of managed-care plans, each party has legislation that bears the identical name: "Patients' Bill of Rights."
And while the bills differ substantially in their reach, both parties' approaches would help only patients who already have insurance, sidestepping one of the main goals of the Clinton health plan -- to extend insurance coverage to people who lack it.
Similarly, in response to a major Medicare reform proposal issued by the White House two weeks ago -- which calls for the insurance program to offer prescription drug benefits for the first time to all older Americans -- Republican leaders have said they, too, are eager to make sure Medicare patients can afford drugs. But the GOP criticizes the administration's approach as needlessly expensive, saying that the government should reach out only to those elderly people who do not already have private insurance to help them pay for medicine.
"The fear of being painted as the party that denied Granny her drug coverage will probably motivate lots of Republicans to push for their proposals, so the voters don't go into the voting booths thinking the Democrats are for drug coverage and the Republicans aren't," said Drew E. Altman, president of the Henry J. Kaiser Family Foundation, a nonprofit organization that sponsors health care research.
Confirming that view, Rep. Thomas M. Davis III (Va.), chairman of the National Republican Congressional Committee, said, "The prescription drug issue . . . is clearly one where you can't come empty-handed."
As such issues dangle before Congress, how large a role they will play in next year's campaigns "depends on how much we get done this year," said Rep. Bill Thomas (R-Calif.), chairman of the House Ways and Means health subcommittee. Thomas is one of many Republicans who contend that Democrats will be reluctant to forfeit campaign issues by helping adopt new health care laws this year -- an accusation that Democrats deny.
With the odds of congressional action uncertain, candidates of both parties are preparing for the issues to linger. At the presidential level, both Vice President Gore and his lone challenger, former senator Bill Bradley of New Jersey, are planning major health care speeches for this fall. Last month, Gore proposed a new offensive against cancer, including a doubling of research funds in the next five years. For his part, Bradley has hinted he will revive the 1993-94 Clinton goal of "universal access to health insurance," but he has given no inkling as yet how he would finance a program that aides say would have to be phased in over a period of years.
On the Republican side, Steve Forbes has outlined a comprehensive program emphasizing insurance reforms, tax incentives, and reliance on vouchers, Medical Savings Accounts and other market-based mechanisms he says will allow individuals greater control over their health care than any government program.
Elizabeth Dole, with a background in the issue from her Labor Department and Red Cross jobs, has urged doubling the National Institutes of Health budget, expanding Medical Savings Accounts and -- like Forbes -- remodeling Medicare to resemble the program already in place for government employees that relies on competition among private health plans.
Bush, who vetoed one patients' rights bill in Texas but signed a modified measure, has not yet spoken to the health care issue, but two of his advisers said he also looks favorably on the kind of Medicare reform that would assure that "America's seniors have access to the same range of choices that members of Congress do."
Sen. Orrin G. Hatch (R-Utah), the latest entrant in the field, says he has sponsored and passed more health care legislation than anyone else in the race -- often with Democratic help. Rep. John R. Kasich (R-Ohio) also has wrestled with these issues as chairman of the House Budget Committee. Kasich has signed a Catholic Hospital Association pledge to address the problem of the 43 million uninsured if he becomes president.
Polling by the Democratic National Committee has convinced strategists that the Medicare issue -- and especially the addition of a prescription drug benefit -- is dynamite. Celinda Lake, a pollster who has just joined Gore's team, said recently that "our advantage [over the Republicans] on Medicare is twice what it is on Social Security. Health care is a huge issue for nonsenior women," who often shoulder the responsibility when children or parents fall ill.
Bill McInturff, who polls for Republicans and the health care industry, said, "When you ask people what they personally feel concerned about, health care always emerges in the top three." During the last few months, McInturff said, the number of people saying the health care system needs "radical change" has jumped up to the highest level he has seen since 1991-92. He attributes the change to "more worries about out-of-pocket costs, a growing concern about the uninsured and frustrations with the managed-care plans."
The recent Battleground Poll, on which Lake collaborated with Republican pollster Ed Goeas, suggested congressional Democrats have virtually a two to one advantage over congressional Republicans on the issues of Medicare and improving the health care system. Gore led Bush by 12 points on those issues.
The visceral nature of these issues was evident last week to Health and Human Services Secretary Donna E. Shalala, who said she attracted among the largest crowds she ever has drawn during a four-state swing, with congressional Democrats in tow, to tout Clinton's new Medicare plan. "There is growing unhappiness with the health care system," she said.
And as politicians such as Wise and other House Democrats who have commissioned studies of drug prices have sensed, that unhappiness offers political opportunities.
"I spend $4,000 a year on drugs. I need a little relief," said Alvin Semer, 92, a retired scrap metal dealer in Chicago. "I do pretty well on Social Security, but I can still use a break."
Arthur Klapper, 79, lives with his wife in Marina Del Ray, Calif., and has no insurance coverage for prescription drugs. "Now, we are taking pills . . . running about $150 a month," he said. "Society has an obligation, and that's where Congress comes in."
As he weighs his votes next year, the candidates' stance on drug coverage "would be a factor," he said. "People like us have a voice that should be heard."
Special correspondent Cassandra Stern in Los Angeles and staff writer Liz Leyden in New York contributed to this report.
The New Generation of Health Reform
What is getting worse
More Americans are uninsured: The number of people without health coverage has been increasing by about 1 million a year through most of the 1990s and now stands at more than
Medical costs are going up: After years of stability, the cost of medical care is rising again, with drug prices leading the way. Over the next decade, the nation's spending on health care is expected to double to $2.1 trillion.
Medicare is running short of money: The federal health insurance program for Americans over age 64 has been spending less money lately, but the program's fund that pays for hospital bills nevertheless is expected to become insolvent in 2015 without further government action.
What government officials are thinking about doing
Patients' rights: The Senate is scheduled to have a four-day debate this week on whether to increase regulation of managed-care plans. Similar legislation is being considered in House committee.
Medicare reform: A bipartisan federal commission debated how to strengthen and modernize the insurance program, but could not reach enough agreement to give advice to Congress and the White House. President Clinton issued his own reform proposal last month. The Senate Finance Committee is working on a bill.
Prescription drugs: For now, the most popular aspect of Medicare reform. Members of Congress have put forth several approaches, including one that would require pharmacies to offer elderly patients better prices and others that would extend drug benefits through Medicare. Clinton has recommended the program offer to pay half the drug costs for all elderly patients up to a limit, in exchange for a monthly fee. Many Republicans believe the government should help only patients with low incomes who do not currently have access to private insurance for drugs.
Medical records confidentiality: Some protections were part of a banking bill that passed the House this month, but the main confidentiality bill has been stuck in a Senate committee. Under a 1997 federal budget agreement, the Department of Health and Human Services will be allowed to impose regulations later this summer if Congress does not act.
Access to care: Several Republicans are recommending different approaches to make insurance more affordable for individuals and for employees of small companies. They tend to involve altering the tax code and tapping the private marketplace.
Long-term care: Clinton has recommended tax relief for elderly people who need nursing homes or other long-term care, or for relatives who care for them at home. A rival GOP plan in the House would offer similar help but emphasizes tax breaks for people who buy a recent form of long-term care insurance.
CAPTION: Prescription for Popularity (This graphic was not available) Democratic aides on the House Government Reform Committee have generated rave reviews for members by cranking out district-by-district studies of prices elderly constituents pay for drugs. Fifty-five Democrats have released studies so far; four dozen more plan to do so.