Health Care: A Bolt of Civic Hope

In an anti-political time the politics of remedy is still possible. Two congressmen, one liberal, one conservative, both versed in the relevant complexities, agree on the bones of a plan to insure the 44 million Americans without health insurance

NAME a nettlesome social problem -- your favorite measure of cultural woe -- and chances are that today's record-long economic expansion has the statistics on it moving in the right direction. Violent crime, welfare rolls, child poverty, teen pregnancy, suicide, abortion, and divorce are all down. Jobs, SAT scores, air quality, the Dow, charitable giving, and even wages for less-skilled workers are all up. The trend lines are almost uniformly encouraging -- all except one.

The number of Americans without health insurance has soared during the current boom, from 37 million in 1993 (when Bill Clinton said it was a national problem requiring immediate attention) to 44 million today. Why? In part because so many of the jobs being created are at the low end of the labor market, where employers can't afford to offer health benefits or, if they do, employees can't afford to pick up their share, and in part because health-care costs -- after a brief respite in the mid-1990s, thanks to managed care -- are on the rise again, leading smaller firms to drop coverage. Experts say that the number of uninsured people could soon rise to 50 million if times remain good, and to 60 million or more if the economy dips.

More than four in five uninsured Americans work year-round or live in families headed by someone who does. These waitresses, taxi drivers, and plumbers earn too much to be eligible for Medicaid but too little to buy coverage in the notoriously high-priced market for individual policies. They contract preventable diseases and are avoidably hospitalized more often than the insured, and are vulnerable to devastating financial loss from illness in ways unthinkable in other advanced nations. To be sure, some folks go without insurance only briefly, and a few who can afford it go without by choice (mainly people in their twenties who feel certain they'll live forever). But "the hard fact is this: the percentage of the population going without insurance involuntarily is growing year after year, in good times and bad," as one politician wrote his colleagues last year. "This is clearly a structural problem we ignore at our peril." The writer? House Majority Leader Richard Armey, of Texas.

Yet ignoring the problem of the uninsured is one of the few things that both Democrats and Republicans seem eager to do in the current presidential campaign. George W. Bush wants to offer tax subsidies of up to $2,000 per family to buy private insurance. But decent family policies cost more than twice that amount. And the roughly $10 billion a year Bush says he will devote to his plan means that his vaunted "compassion" will touch only a small fraction of the uninsured. This might not be surprising from a Republican candidate save for one striking fact: Bush's father in 1992 offered a version of the same plan that was considerably more generous -- $5,100 per family, adjusted for inflation, at a cost of $50 billion a year. And the father offered his generous plan when the federal budget deficit was nearly $300 billion; the son puts forth his token gesture at a time of comparably outsized surpluses.

Curiously, this shrinking of ambition when federal resources are finally available on a scale equal to the problem also characterizes the Democrats. Vice President Al Gore is offering a patchwork of coverage extensions, mainly for children -- who, because they incur fewer costly illnesses than adults, are a bargain to insure. His plans are a pale shadow of what the Administration was aiming for back when the problem was smaller.

Why are our leaders content to let the problem worsen while our means for addressing it have grown? The unflattering answer is because doing so is both safe and cheap. Today's uninsured are low-income workers with little political voice; in the broad-based recession of the early 1990s it was middle-class anxieties that had politicians scurrying to respond. A policy of rationing health coverage by income also saves money. The uninsured do get care in emergency rooms, county hospitals, and other sites of last resort. But these citizens consume just two thirds as much in health resources as their insured neighbors, because they don't get preventive care, regular checkups, and other services most people take for granted. We can fix the problem of the uninsured only by spending more money on people with little political clout -- and, if necessary, by somehow disguising that this is what we're up to.

Any such attempt, of course, will take place in the shadow of the Clinton health fiasco of 1993-1994. The political lesson both parties drew when Hillary Clinton's bulky plan was attacked unfairly as "socialized medicine" but quite fairly as too complex was that efforts to expand coverage must be incremental. "Step by step" is the approved mantra.

Yet incremental "achievements" since 1994 have been a bust. Senators Ted Kennedy and Nancy Kassebaum sponsored a bill passed in 1996 that was hailed by both parties as a model for future health reform. The measure was supposed to guarantee continued access to insurance for those who changed or lost their jobs. But insurers were free to charge whatever they liked in these situations, and people quickly found that "access" meant very little when a policy might cost $15,000 a year. Similarly, a plan costing $5 billion a year for the nation's 10 million uninsured children passed with great fanfare in 1997; aid was targeted so narrowly and complexly, however, that only one in five children it was meant to reach have been signed up. Bolder proposals, meanwhile, have proved easy to shoot down as unaffordable. Just ask Bill Bradley.

Indeed, in a year when a Democrat won his party's presidential nomination by attacking another Democrat for trying to insure all Americans, it is tempting to declare universal coverage a lost cause -- tempting but wrong. As it turns out, circumstances have quietly evolved in recent years in ways that leave both parties ready to make an ambitious push, together, on health coverage. This has taken place in a way scarcely visible in the Capitol's day-to-day political jockeying, but the parties, as they align, are poised to produce a movement of surprising power. Republicans, reeling from the failed "revolution" of Newt Gingrich and their associated image as uncaring thugs, have looked for ways to address the frustrations wrought by managed care. Many believe that giving voters more power to choose their health coverage will derail heavy-handed Democratic efforts to regulate private health care. At the same time, many liberal Democrats have come to terms with the fact that power in Congress will be roughly balanced between the parties for the foreseeable future. They've therefore become open to ways of expanding coverage that were once ideologically out of bounds. It sounds perverse, but some optimists say we're just one good recession away from seeing the political energy unleashed to solve this problem.

Luckily, we don't need a recession, because there's a pragmatic solution at hand that can command bipartisan support: tax subsidies for people who need help to buy insurance from competing private health plans. This is basically the scheme that President Bush offered in 1992 and that his son -- in embarrassing (but expandable) miniature -- offers today. It is the same general idea that Bill Bradley pushed earlier this year, and that policy analysts from shops as diverse as the Democratic Leadership Council and the conservative Heritage Foundation have been refining for a decade. A few bipartisan groups of legislators have put forth tiny versions of such a plan, but the time will be ripe after next month's election for the real thing. And although tax subsidies are not perfect (experts say, for example, that the poorest Americans will still need programs of direct aid and better-funded local clinics), and plenty of details remain to be thrashed out, this scheme offers the most realistic way of bringing the parties together to right an enduring wrong.

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