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THIS STORY HAS BEEN FORMATTED FOR EASY PRINTING
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The battle lines on health care
By Thomas Oliphant, 11/26/2002
Where the country's health care crisis is concerned, we have on the left that famous, wacky liberal dreamer, Al Gore, now pushing what is most accurately called national health insurance.
In the center, there is a more famous apostle of moderate and mixed-bag policy wonkery who relies heavily on the private sector for his latest proposal - Edward Kennedy.
On the right, there is the familiarity that ought to breed contempt - President Bush, still trying to fit the square peg of tax credits into the round hole of immense gaps in basic coverage for working families.
Bush is the easiest to dismiss. As usual, the right's approach to a major domestic problem is to focus on those least affected by it. Tax credits primarily help those already insured or able to pay for it up front; even if made refundable, they are a false promise because the majority of the 41 million uninsured work full time for incomes too low to generate the cash. Worse, the tax credits' proposed ''value'' wouldn't pay half the costs of a decent plan and ignores the reality of skyrocketing costs.
Indeed, the president is so far out of step that his own secretary of health and human services, Tommy Thompson, requested a National Academy of Sciences report that recommended a series of state-level pilot projects to, among other things, test ways of actually achieving full coverage.
Gore and Kennedy are more interesting because they are trying to face squarely a true mess of lousy coverage, soaring costs, and diminishing access that has only been metastasizing for a generation.
The oversimplified image is of antagonism between Gore's advocacy of ''single payer'' (read, government) insurance and Kennedy's proposal for a hybrid approach to universal coverage that builds upon the employer-based system that already reaches more than 160 million people, though increasingly with less benefits and frighteningly higher costs.
The truth is that Kennedy - the national leader on this issue and author of the first serious proposal, a single-payer scheme, more than 30 years ago - thinks that what Gore has done is terrific, has raised the problem's profile, and has elevated the discussion.
Gore's argument (details of an actual plan to come next year if he runs for president) is that the point of no return has been reached in a collapsing system. When he ran in 2000, by contrast, Gore (supported vocally by Kennedy) was an advocate of private-public incrementalism against former senator Bill Bradley.
In fairness to Gore, it is not true that he went after Bradley's advocacy of universal coverage per se. What he attacked were two large holes in Bradley's proposal: the failure to invest in Medicare and the proposed abolition of Medicaid for the poor and people in nursing homes without a replacement of equivalent value.
When Gore says ''single-payer,'' he means one source for receipts and expenditures in place of today's multitude of insurance operations. It is national insurance, not nationalized medicine, and it can leave every bit as much choice on coverage and care as exists currently. To oversimplify, single-payer is analogous to having Medicare for everybody, with the same individual freedom to buy more if you can afford it.
As Kennedy notes, the advantages of such a system, in addition to simplified universality, would include an efficient means of attacking soaring costs. Just as an example, the official estimate under the status quo is that the absurdly duplicative administrative costs of private-sector bureaucracies gobble up nearly one of every three health -care dollars.
Kennedy, however, is now advocating a solution crafted for the HMO Age and based on the employer-provided networks that use private insurance. It would build at once on the new program of low-income insurance for children that bear his and Republican Senator Orrin Hatch's names.
There is no excuse not to expand efforts to enroll every eligible child in the program or in Medicaid, and a sensible expansion would take in the uninsured parents. As Kennedy noted in a speech at Harvard last week, 75 percent of all uninsured children are already eligible for the two programs, and one in five uninsured adults is their parent.
The cornerstone of the Kennedy proposal is a universal coverage modeled after the multiple-choice plans available to federal employees (including George W. Bush and every member of Congress). Getting there would require a mixture of clear mandates on large employers (the vast majority already provide coverage) and creative help (tax credits and risk pooling arrangements) for small business and the self-employed.
The conventional wisdom may be that a battle is brewing on the left, to the delight of the right. In fact, Gore's recent move has increased attention to a national crisis that is President Bush's responsibility and for which he has nothing to offer.
Thomas Oliphant's e-mail address is oliphant@globe.com.
This story ran on page A19 of the Boston Globe on 11/26/2002.
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