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The other big issue is how to pay for health insurance for millions of Americans. President Bush speaks about healthcare policy today in Ohio. He wants to restrain spending on federal health insurance programs. He also wants to expand health savings accounts. It's a more modest agenda than the last president's plan, but may not be any easier to pass.

Here's NPR's Julie Rovner.

JULIE ROVNER reporting:

Having sailed last year to get Congress to create private accounts for social security, this year President Bush is taking broader aim, including the other major federal entitlement programs for healthcare.

President GEORGE W. BUSH: The other Medicare, Medicaid and Social Security are now going faster than the economy, faster than the population and nearly three times the rate of inflation. And the retirement of baby boom generation will put even more strains on these programs. By 2030, spending for Medicare, Medicaid and Social Security alone will be almost 60 percent of the entire federal budget.

ROVNER: This being an election year, the President has chosen the safe way out of directly pursuing such an ambitious goal; he wants to appoint a bi-partisan commission.

President BUSH: The commission will include members of Congress from both political parties. It will recommend long-term solutions that will keep the promise of these vital programs while addressing their growing costs.

ROVNER: Yale public policy professor Ted Marmor says commissions like these generally have two purposes. They're either intended to punt a thorny issue off the agenda for awhile or else to hammer out an emerging solution as the famous 1983 Social Security Commission managed to do. But he says this commission actually has a third purpose in mind.

Mr. THEODORE MARMOR PHD (Professor of Public Policy and Management and Professor of Political Science, Yale University): To frame the conversation in America about entitlements and to suggest that entitlements represent a kind of slow moving tsunami that requires massive action or massive reform in order to avoid the flooding that will happen in the absence of it.

ROVNER: In fact, says Marmor, that's not necessarily the case at all.

Mr. MARMOR: I think it's sheer and utter nonsense. I mean, when you start using projected troubles in 2042 or 2052 as a reason for action in 2006, you know what? you need medical care.

ROVNER: In the case of healthcare, Marmor agrees with the President that Medicare and Medicaid are growing more rapidly than the rest of the economy and consuming a growing share of the nation's output.

Mr. MARMOR: But that's not because of the structure of Medicare and it's not because of the structure of Medicaid; it's because of forces in American medical care that are not counter-veiled by the structure of our public policies.

ROVNER: In other words, what plagues the two big health programs is what plagues the system as a whole, and Marmor says the administration's proposed solution, to make people more responsible for the cost of their own healthcare, may solve the government's problem, but only by shifting the cost to individuals.

Mr. MARMOR: This distinction is absolutely crucial. There is a huge difference to American patients between the costs of medical care to the government and the costs of the medical care to them. What the government is proposing is restricting the cost to the government and shifting the burden of the cost to them.

ROVNER: Administration officials deny that's their ultimate goal. Because Medicare and Medicaid are so big (accounting for nearly half the nation's healthcare bill), improvements to them can in turn force improvements to the rest of the system as Health and Human Services secretary Mike Leavitt pointed out earlier this week.

Mr. MICHAEL LEAVITT (Secretary, U.S. Department of Health and Human Services): Medicaid and Medicare are extraordinarily important players in healthcare reform so as we're reforming the 46 percent side of that equation, we're also having an impact on the 54 percent.

ROVNER: In fact, Kaiser Family Foundation president Drew Altman says when you put them all together, the President's plans for Medicare, Medicaid and health savings accounts do have much in common: they all depend on shifting more responsibility to consumers.

Mr. DREW ALTMAN (President and CEO, Henry J. Kaiser Family Foundation): And because it's happening just in pieces and in little steps, we're not having a real public discussion and debate about the real underlying principles and values and what it all means like we did when we had a giant Clinton health reform plan right in front of us that everyone could see and touch and debate.

ROVNER: Given the outcome of that debate, maybe it's no surprise this administration is pursuing a more understated approach. Julie Rovner, NPR News, Washington.

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