Prometheus 6   

The perfect prescription

Everyone has a health care reform plan. But the best approach to covering the uninsured isn't even on the table.

… Today, this jury-rigged system is almost perfectly structured to stymie constructive action. Begin with a simple fact: Most Americans are insured. While an inexcusable 15 percent lack coverage (and perhaps twice as many were uninsured at least once in the past two years), most have real, if often inadequate, coverage most of the time.

This helps explain why the biggest insurance issues of recent years-for example, the Patients' Bill of Rights-have concerned the insured, not the uninsured. It also explains why every one of the leading presidential contenders is vowing to build on the current system of employment-based insurance. Only one longshot candidate, congressman Dennis Kucinich, has bucked the trend with a proposal to expand Medicare to all Americans.

Yet even when building on the existing patchwork system, tackling the problem of the uninsured generally entails a Hobson's choice: Either create programs with big price tags that deliver most of their benefits to those who already have insurance, or create narrowly targeted programs that isolate recipients politically while still leaving many without protection.

The first, more ambitious approach has only one major exponent in the presidential race, congressman Richard Gephardt, but his plan is undeniably bold. It would give employers tax credits that would offset up to 60 percent of the cost of insurance; in turn, employers would be required to provide coverage. Lower-income workers would get bigger tax credits.

…In contrast, most of the other Democratic candidates have taken the second tack, offering plans that are essentially souped-up versions of the status quo. Howard Dean's proposal, building on the plan he pushed in Vermont, would expand Medicaid and the State Children's Health Insurance Program (S-CHIP) to more lower-income families. Senator John Kerry has a similar blueprint; Senator Bob Graham suggests he will develop one.

… Is there a third way? Not one that will please all sides. But it's surprising that Democrats have not revived the single truly original idea that emerged out of the Clinton-era debate: ''play-or-pay.''