Bush and Gore tinkering at the edges of the medical insurance minefield

Bob Warner and Pat Koenig are clearly enjoying their retirement in the sunshine state. Both show no signs of ill health but both reply the same way - "Medicare" - to the question "What is this election about for you?" That's the same answer one will get from all too many of the 20 per cent of Florida's voters who are retired.

Medicare is the health system aimed at the elderly, but it is not just the elderly who are concerned about this issue. In the richest country in the world even the middle classes shudder when they think of what could happen to them if they fall ill. Some 44 million Americans, most of them the working poor, are neither covered by the state safety net Medicaid system nor by private medical insurance - that's one in six of the population, 11 million of them children.

And things have been getting worse, with the number of uninsured rising by a million a year since 1987 and only beginning to decline last year.

The result has been an increasing reliance by families on visits to emergency rooms for the sort of care the local doctor would normally provide - up 3 per cent a year since 1987 and 8 per cent last year. In New York City, three-quarters of visits to emergency rooms are for non-emergencies, according to a recent study. The Medicaid system should cover those earning less than twice the national poverty rate - for a family of four that's $34,000 - but some states, like George Bush's Texas, don't even extend Medicaid that far. Texas heads the national league for the uninsured at 27 per cent. Insurance costs are up 8.3 per cent this year and have risen 98 per cent since 1990. The average cost to cover a family of four is put at $7,000 a year.

But it's not only the uninsured who worry. Bob Warner is also deeply concerned about prescription drug costs for the elderly, one-third of whom are not covered by insurance or the Medicare system for the elderly and 70 per cent have to top up their cover. For many elderly that means cutting back on what they need or relying on charitable donations by drug companies. These are not just the poorest - 40 per cent of those without drug cover have incomes at least twice the national poverty limit.

Yet neither candidate of the major parties is proposing to do more than tinker with the system - each would spend between $120 billion and $130 billion extra over 10 years. Small beer.

Badly burned by the failed Hillary Clinton reform agenda of 1993, the Democrats have shied away from anything that might smack of government control of healthcare.

Vice-President Al Gore is targeting children and the elderly, with proposals to raise Medicaid eligibility limits by 25 per cent and to pay part of the cost of prescription drugs for the elderly. To extend health insurance, both are proposing tax credits of 25 per cent of cost of cover in the Gore case and up to $2,000 for families in the Bush case.

Mr Bush's emphasis is on tax cuts and restructuring Medicare provision to make it more competitive, and therefore cheaper, and he proposes spending about half what his opponent does on subsidising drug costs. He would also assist small businesses to band together to buy cheaper cover for their workers.

Both support the idea of a patients' bill of rights, which would ensure patient access to emergency and specialist medical care, provide financial incentives to doctors to limit treatment of patients and permit patients to sue insurers if they believe they have been harmed by coverage decisions.