eorge W. Bush offers elderly people a deal: In exchange for prescription drug aid to the poorest, they would get a revised Medicare system - with drug benefits - that is weighted in favor of managed-care plans. Many older people have no experience with managed care and have chronic conditions that would test the financial ability of the plans to pay for treatment. They - and the voters - ought to think twice before accepting this trade-off.
Bush, the Republican presidential nominee, would provide impoverished elderly with prescription drug assistance more quickly than his Medicare managed-care initiative would take effect, and that is all to the good. Many need help immediately. But he would offer his prescription drug benefit through the states. Massachusetts would quickly take advantage of extra federal money, as it did in 1997 to provide health insurance for children. Other states would be laggard. Governor Bush's Texas only began signing up children for the program this May.
Bush has faith in the ability of managed-care plans to offer a comprehensive range of benefits while staying within whatever premium the elderly and the federal government are able to pay. He does not mention the difficulties of managed care under the Balanced Budget Act of 1997. In that bill Congress approved a series of initiatives intended to encourage plans to cover the elderly, but it also limited rates of reimbursement. Many plans either cut benefits or withdrew from sections of the country where they could not make money.
Bush is vague on the details, but he does say that nobody making 135 percent of poverty or less ($11,300 a year for an individual) would pay Medicare premiums. Those above that level would face a cost yet to be determined, although Bush would hold them liable for no more than $6,000 a year in catastrophic medical expenses. That still leaves much leeway for plans to recoup their costs by raising premiums to people with modest incomes.
Managed care, at its best, offers a comprehensive set of services to keep people out of the hospital, thus saving money and enhancing a person's well-being. It ought to play a significant role in Medicare.
And Bush is right that Medicare will face a financial crisis when baby boomers collect benefits. A national dialogue is needed about how the nation will pay for the program, but by ruling out tax increases, Bush ensures these discussions will be one-sided. He wants Congress to approve a Medicare reorganization plan next year.
Medicare was designed for 1965 conditions, when hospitalization, not drugs, was a major source of financial worry for the elderly, and it includes no drug benefit. But there is no consensus on Medicare reform, and it will take years to develop one. Older people of all income levels with huge drug bills need help now.
''Since 1965, more than 80 million American seniors have found a measure of security - a measure of confidence and dignity - in Medicare,'' Bush said this week. The next administration needs to enhance that security without rushing through a plan to disrupt the system that provides it.
