John McCain has proposed revamping Medicare’s payment system to reward doctors who produce better health outcomes. But for the most part, the candidates’ prescriptions for Medicare nibble around the edges of the drug benefit instead of addressing the system’s long-term sustainability.

John McCain’s proposal

McCain, who voted against the drug benefit in 2003, would accelerate the introduction of generic drugs and allow the re-importation of U.S.-made drugs that are sold more cheaply in other countries. Before Part D, savings-conscious seniors bought drugs in Canada and Mexico. Today, re-importation means very little, since Part D has taken some of the sting out of high prescription costs.

The faster introduction of generics will hardly help Randle. He takes mostly brand name drugs; when they are too expensive, the free medicine he gets while in the donut hole continues to tie him to drug companies’ more expensive brands—which, of course, means higher mark-ups and market share.

Barack Obama’s proposal
Obama would promote the use of generic drugs. OK, maybe Randle can go to Wal-Mart and cheaply fill some of his prescriptions with generics. Doctors would have to agree the generics would work well for him. Plus, he would need some consumer education to make the switch, and must be willing to give up the free drugs while he is in the donut hole. It would be a cost/benefit calculation. Obama would allow the federal government to negotiate prices of pharmaceuticals used by Medicare recipients. When Congress established the drug benefit, lawmakers banned the government from negotiating cheaper prices, as it does in the VA system. So far, Congress has failed to overturn the ban. If the new Congress can do that, the price of drugs for Randle might drop, and he wouldn’t reach the donut hole as fast. But it’s unclear whether price negotiation will affect the system’s long-term fiscal health.

Since we don’t know where the candidates stand on fixing the overall finances of Medicare, it’s hard to say which candidate would help or hurt Randle the most. Cutting benefits to shore up the system would certainly pinch, since he would have to finance more care from his own slim income. Increasing premiums and copayments for certain Medicare services would also hurt him. One solution on the table is making wealthier beneficiaries pay more for their benefits, either through higher premiums or higher coinsurance, a move that some say leads to the further privatization of Medicare. Even if Congress defines “wealthy” as incomes around $50,000, which a few experts think could happen, Randle’s very low income keeps him safe for now.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.