HEALTH CARE/Joan Retsinas

Parallel Universe that is Washington

Earth to members of Congress. Tune out from Nirvana for just a few minutes. You live in an enchanted land. In your universe, spending drives up deficits, but the deficits don't matter. Poor people serve canapés and drive cabs. Sick people are invisible -- too weak to come see you, too poor to hire lobbyists. You mingle all day with colleagues and contributors, who look, talk and think like you. What a paradise!

No wonder you zeroed in on a health crisis that nobody outside Nirvana recognized as a crisis. Looking out at the causes begging for your attention, and your dollars, you saw the millions of elderly voters. They have Medicare, a universal insurance program for all Americans age 65 and older.

Is that enough? How can we improve it? You just proposed yet another benefit to Medicare, beyond the multi-billion dollar drug rider added last year. This session you are considering legislation to add ultrasound aneurysm screening to the Medicare package.

Diagnosic ultrasounds are a useful screen. They can identify aneurysms in the abdominal aorta. As many as 15,000 people die each year from these aneurysms, and the simple test can detect the condition. The advisory United States Preventative Services Task Force recommended the test for people most at risk: men ages 65 to 75 with a history of smoking.

You in Congress, though, went beyond the panel's recommendation. You have proposed legislation to offer this test to all beneficiaries, regardless of their risk. Nestled in your parallel universe, you saw the lack of coverage for this screening test a crisis worthy of federal action.

Every Medicare recipient thanks you. But please, tune into the Real World USA, and look at some crises you don't see in Nirvana.

The Uninsured: 45 million Americans have no health insurance at all -- no coverage for drugs, for routine check-ups, for emergency surgeries. Nobody will pay for blood tests, colonoscopies, Pap smears, bone density tests, let alone diagnostic ultrasounds.

Most of these people work -- they may be the ones serving you canapés. Either they work for employers who don't offer health insurance, or if their employers do offer it, they can't afford the premiums.

Do the math. On a $25,000 annual income, how much can a family afford for health insurance, after paying for rent, food and utilities? If the math eludes you, talk to the people serving the canapés. If those people work part-time, moreover, they probably don't even have the option of buying health insurance: Only 20% of American part-timers have health insurance, only 24% have sick leave and only 14% have short-term disability insurance.

The Health-Poor: For people without insurance, health care bills are catastrophic -- thousands for an appendectomy, hundreds of thousands for quadruple bypass surgery. Even for people with insurance, health care bills can be onerous. Last year half of the 1,600,000 bankruptcies were linked to a "bankrupting illness".

At the onset of the illness, more than 75% of these people had health insurance. And, not surprisingly, over the course of the illness, as people grew too sick to work, they lost their jobs and, with their jobs, their insurance.

Distressingly, people who don't lose their insurance can still have bankrupting illnesses. In Real World USA (not in Congress), we have the phenomenon of the under-insured. These people discover that their illness, and the requisite treatments, fall outside their benefits package.

The Poor: We do have a safety net. In 1965 Congress pledged to partner with states to give poor people health insurance. Under Medicaid, the federal government would pay part of the tab, and a higher percentage in poorer states.

Fifty million people have coverage via Medicaid. During the last few years, states have been struggling to pay their share of the tab. Roughly 22% of state budgets go to Medicaid, so states have been ratcheting away at the program -- raising eligibility levels, lowering payments to providers, reducing benefits.

And the federal government has been encouraging this erosion. Indeed, most recently the administration has threatened to slash $60 billion from this program for poor people. Of course, if states pare their Medicaid budgets, those people will end up in the ranks of the uninsured.

Most Americans see these as health care crises. Of course, most Americans don't live in the Congressional Nirvana.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

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