HEALTH CARE/Joan Retsinas

Wallflower at the Dance

She's huge, ungainly, incredibly clumsy. She's profligate. She's bossy. Her tempo is off -- she's a few paces behind everyone else on the floor. Yet all the presidential candidates will have to dance with her if they hope to stay on the floor.

The "she" is the federal government -- the trillion-dollar behemoth, ruled by a mercurial batch of politicos who take their orders from a more mercurial electorate, and managed by bureaucrats trapped in the bizarrely complicated rules they keep crafting. The dance is "The Uninsured Waltz."

Each election cycle the dance begins anew. Candidates whirl around the floor to other tunes. Campaign finance reform, abortion, nuclear test bans, gun control -- all have their own refrains. The Uninsured Waltz is one of many dances -- yet with 44 million uninsured Americans playing the music, candidates cannot sit this one out.

Some of the expected partners have been around this dance floor a few times already and have not proven adroit. State governments, for instance, have a venerable reputation as plausible solutions for the uninsured. They are experienced. For over 30 years states have administered Medicaid. They are flexible, not bound by the rules that make flexibility impossible for the federal government. They are grassroots, if only because state legislatures include middle-income Americans who are not lawyers. President Clinton's Children's Health Insurance Program (CHIP) follows the state model, giving states money to insure children eligible by age (determined by the state) and income (also determined by the state). CHIP covers lots of children; but lots of children remain uninsured. And even optimists doubt that CHIP can cover all children, much less their parents.

Employers are too tired to come to the floor. After the past decade's "pay or play" initiatives, nobody any longer is trying to force this doppelganger tax on businesses. Many small laundromats, restaurants, factories, day care centers ... can't afford it. Recently Bill Thomas (R-California), the chair of the House Ways and Means Health Subcommittee, told the Chamber of Commerce that the current employer-based system is "fatally flawed."

At least for a few whirls around the dance floor, the private insurance market is a plausible, and eager, partner. Senator Bradley wants to let uninsured Americans join one of the health plans open to federal employees. Indeed, the uninsured themselves would like to join one of those plans. The problem is money: most of the uninsured cannot afford the premiums. Ultimately the only plausible payer is the federal government. Senator Bradley, in short, will have to switch partners.

Finally, Republicans especially want to embrace private, tax-paying consumers. With enough tax credits and deductions, these ordinary Americans will be able to purchase their own insurance. Governor George W. Bush -- from Texas, a state where almost one quarter of the population is uninsured -- likes Medical Savings Accounts. Typically a person will buy a catastrophic policy to cover the rare -- he hopes -- catastrophes, while depositing into a special account money for everything else, including drugs, outpatient care, preventive care, annual examinations. These accounts will help the people who can afford them -- but not many of the uninsured can. Tax deductions to help the self-employed buy insurance will also help those who can afford them -- the self-employed venture capitalist, not the self-employed cleaning lady.

Indeed, Rep. Thomas concedes that, even with tax deductions to bolster consumerism, the government would have to require everybody to buy insurance -- and subsidize that insurance for people who can't afford the premiums. But subsidies and mandates will require action from the federal government. He, like Senator Bradley, will have to switch partners.

The countries around the globe that have universal insurance are not demonstrably wealthier than the United States. Nor are they more compassionate. Or more imaginative. They simply have governments willing to spend authority and money to promote the health of the citizenry.

This governmental partner -- however ungainly -- can dance.

Joan Retsinas is a sociologist who writes about health care in Providence, Rhode Island.

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