Bush Holds the Nation's Health in His Hands

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By Stuart Butler, Los Angeles Times

September 22, 2003

Rather than wait for Congress, the president must take the lead in the debate on Medicare reforms.

Most experts I know who think about the long-term health of Medicare are increasingly frustrated about the current debate over adding a drug benefit to the program. Whether they are liberal or conservative, they see crucial issues getting lost in partisan noise and short-term reelection maneuvering.

Although I agree with President Bush's broad vision for Medicare, there is no getting away from the fact that his failure to exercise proper leadership is largely to blame for the current sterile debate.

The leadership function of a president is critically important when it comes to sensitive and complex domestic policy, just as it is in foreign affairs and national security. It's up to him to crystallize national issues, especially when deeply held values are involved and when today's needs must be weighed against future costs. If the president fails to clarify the national agenda, he leaves the door open to political grandstanding and a special-interest free-for-all — as we're now experiencing with Medicare.

For all his faults, President Clinton understood this. He told Americans his presidency would be a "bridge to the 21st century," a preparation for future realities. He launched what amounted to a national town hall meeting on needed Social Security reforms. And, on Medicare, he assembled a national commission to build support for a "third way" restructuring of the program. It was a tragedy that his personal and political problems caused him to pull the plug on that effort.

Bush says he wants to give seniors choice in their coverage, improve Medicare overall and strengthen its financial foundation. But so far he has failed to draw lawmakers and the public into a national discussion about exactly how — and if — we can make that happen. Instead he places himself safely on the sidelines, allowing "the process" on Capitol Hill to unfold — or as cynics might put it, embracing "send me a bill and I'll sign it" leadership.

The problem — as decades of congressional bickering have amply demonstrated — is that Congress is not a forum for conducting a thoughtful national discussion designed to build support for painful decisions. Legislators necessarily pay attention to local and short-term interests.

But sooner or later, fundamental questions must be faced.

For example, can we add a new benefit to a program that even now cannot be sustained without huge transfers of money from our children and grandchildren? It's no secret that the 10-year cost of a new drug benefit (supposedly $400 billion) is peanuts compared with the staggering unfunded costs Medicare faces once the baby boomers start to collect benefits. Have we the right to saddle our grandchildren with an enormous new obligation?

Is it morally and financially responsible to continue to promise roughly equal Medicare benefits to both rich and poor? Should a retired Bill Gates be guaranteed the same benefits as everyone else, when many seniors with modest incomes, even with a drug benefit, would not be able to afford adequate care?

Sen. Ted Kennedy (D-Mass.) threatened to filibuster any drug benefit proposal if rich people were asked to pay more or get less. The president should use his bully pulpit to force Kennedy to make a case to the American people for this curious position and let the people respond.

And the president ought to ask Americans whether detailed Medicare benefits should be designed by legislators who know little about medicine and are under pressure from the health industry and voter groups. Maybe we would get a better Medicare package if Congress could only vote up or down on a proposal developed by an expert panel. Or why not devise a way to let seniors select the range of benefits they want — as members of Congress do for their own coverage?

Lawmakers will not voluntarily debate fundamental questions of values and intergenerational responsibilities. If Congress does anything to remake Medicare, it probably will send Bush a mishmash program that will pass trillions of dollars of costs to future generations and breech most Americans' concepts of fairness.

Rather than sitting in the White House and waiting for a bill, Bush must lead the public debate on the decisions that will affect us for decades. If he flinches from this important duty, he will have failed a critical test of leadership.