Reforming Health Care

Two critical questions are missing from debates over proposed changes

ALTHOUGH it is difficult to draw all the threads of health-care reform together, what portends to be the largest change in one major aspect of our lives since the introduction of Social Security demands our thoughtful consid- eration and involvement.

After hours of television talk about President Clinton's health-care proposals, which now appear to be only one starting point in the congressional debate, two important questions have been overlooked: First, why should the system be connected with, or paid for, by one's employer? Second, is this to be a coercive system, or one that merely makes health care more available to those who want it?

On the first point, health care came to be financed by one's employer over the past generation as a bargaining tactic.

It was partly a fringe benefit, sometimes meant to tie the employee to his present job; it was partly a way to avoid limits on outright wage increases, particularly during World War II. Yet, the availability of medical care bears no logical connection with one's employment history, unlike Social Security, which is closely tied to one's wage history over his or her working life.

Moreover, many of the people who currently are not covered by any health insurance are in the category of either the chronically unemployed or the several million who are at any one time involved in a job switch.

There is no valid argument for continuing to tie the plan to one's employer, other than the obvious and dubious one that if the employer pays most of the bill, its true cost is hidden from the public, at least for while.

If we are talking about real reform, the first step should be to disconnect its financing from the workplace.

Second, if this is to be a coercive program (as I understand the president's intent that ``every American must be covered''), then call it a government program and include it in the general budget.

Because of the modestly progressive nature of the federal income tax, the rich will likely pay more than their pro-rata share would otherwise cost, but since universal health care is supposed to benefit the society at large, this is at least as justifiable as our approach to buying warships and missiles with our taxes.

BUT what if we shrink from that word ``coercive''?

Then we want to design a plan in which the government does oversee the accessibility of health care. Yet as much as we may dislike coercion, accessibility alone is insufficient. It leaves out too many people who are on the margins of society, the very people whose treatment in emergency rooms runs up the costs for everyone else.

Thus, a strong argument can be made for universal coverage at some level, with what the profession calls preventive medicine to be included, to be paid for out of general revenues. Some competition could still remain in the system by allowing competing groups in each state to bid for the business.

Let us begin at the beginning if this is to be real reform. The two questions whose answers need to be clear, are: Should the system of financing be disconnected from the workplace, with which it has no intrinsic connection? And if some level of health care is to be guaranteed for all, why not fund it out of the federal budget?

If the Congress will consider the basics of what is involved, it will, I think, find both of these questions worth answering as starting points. The Opinion/Essay Page welcomes manuscripts. Authors of articles we accept will be notified by telephone. Authors of articles not accepted will be notified by postcard. Send manuscripts to Opinions/Essays, One Norway Street, Boston, MA 02115, by fax to 617 -450-2317, or by Internet E-mail to OPED@RACHEL.CSPS.COM.