By every indication, the November 2 elections will not turn on health care issues. The war in Iraq, al-Qaeda, the national economy, and the personalities involved are far more emphatic in the daily news, in party platforms, and in the utterances of candidates.

This does not suggest that health care is unimportant. Resumption of double-digit annual increases in national spending, the failure of 40 million Americans to find any health care insurance, the medical malpractice crisis, the cost of pharmaceuticals, the push for managed care, and, most of all, the matter of privatizing Medicare along with Social Security all deserve national debate and thoughtful attention. They will not get it in the next weeks.

The current political climate in Washington has grown more strident with moderates in both parties having difficulties in finding any common ground on which to legislate. The intense antagonism that many Republicans exhibited toward Bill Clinton are returned in kind by Democrats against George W. Bush. The difference is that many attacks on Bill Clinton related to his personal conduct while most of those against George Bush address his management of national security and the economy.

The growing crisis of health care availability and costs reflects the absence of any significant government initiative since the 1993 demise of the Clinton reforms. Those would have put most Americans into managed care systems paid by employers, operated by insurance companies, and regulated by a new government bureaucracy. That did not happen. But look closely at what is now proposed. The next federal activity of note was the passage last winter of the misnamed Medicare reform bill. The most visible issue in that was limited pharmaceutical benefits to Medicare beneficiaries. More substantive, if more complicated to follow, were provisions to subsidize insurance companies to offer managed care packages, a 2-year sop of annual 1.5% increases in Medicare payments to doctors, and a series of legislative guarantees that the government would take no action that could restrain the costs of pharmaceuticals. For doctors, the 2-year grace period will end with the return of annual adjustments that could cost as much as 10% reductions unless Congress again intervenes. Pharmaceutical coverage will not take effect until 2006. The interim programs are confusing, dependent entirely on private entities to scheme up and offer and, thus far, of little appeal to Medicare beneficiaries. The AARP, after supporting the bill, wrote its members to assert that its own pharmaceutical discount programs were better than what the bill seemed to offer. But, in terms of the election, the question is whether voters will be persuaded that the bill was a responsible action or whether it was a payoff to drug makers, the insurance industry, and health care providers. Most of the subsidies in the bill go to these folks, with only a fuzzy tax credit to poor folks, who pay few taxes anyhow.

In August, when this was written, it seemed potentially instructive to read statements about health care in Bush/Cheney and Kerry/Edwards web sites. The potential was not realized. The Bush/Cheney material, coming before the Republican convention, was much shorter. Three brief pages asserting good deeds done or intended are followed by three pages explaining why the Kerry proposals are flawed fatally. The Kerry/Edwards material, post convention, goes on at much greater length about lowering costs to patients, expanding coverage, emphasizing efficiency, reducing waste, stopping fraud, and, of course, improving quality. The principal assertion is that health coverage somehow and by someone would be extended to all Americans. The example of quality to be achieved is the health care provided for members of Congress. Some years ago, Al Gore proposed that health insurers offer the public the same packages they offer to federal employees. That reasonable idea sank without a trace.

American health care accounts for one dollar in six in the gross domestic product, the highest spending among developed countries. Arguably, such spending is good because Americans generally have access to “good health care.” Health care money is spent by Americans for American-made goods and services. But that would posit that the system delivers equally and efficiently for all Americans. So neither side will touch this issue.

Given the size of the federal deficit all incurred in the past 4 years, and federal tax cuts that inhibit deficit reduction but not most other government spending, the new president will not have enough money to make improvements or to pay for the natural growth of existing public programs. Historically, Democratic administrations have been more sympathetic to funding health care and medical research than have been the Republicans. If a Democratic president confronts a Republican Congress, or the obverse, nothing will happen. Probably, not much will happen in health care in any case.

Otha Linton is a journalist based in Potomac, Md, who has written extensively about health care. For 35 years, he served in various capacities at the American College of Radiology, Reston, Va.