The Candidates Need More Than a Patchwork Approach to Health Care

WASHINGTON -- In the midst of a Democratic convention that is high on psychodrama and necessarily low on wonkish detail, it hardly seems fair to throw around a word like "entitlements." Besides, Republicans are set to commandeer the media spotlight with their own convention next week, and they can be expected to use the E-word once or twice, probably with modifiers to make it sound dirty. Examples: references to "runaway spending'' on "entitlements" and the need to "rein them in."

So it is worth pausing during these orchestrated partisan celebrations to look afresh at entitlements. There is no more recent evidence of their enduring value than the latest report from the Census Bureau on the number of Americans who are doing without health insurance.

The headline seems counterintuitive, if not downright baffling: The number of people without insurance dipped in 2007, falling from 47 million to just under 46 million. Did the private insurance industry suddenly make it easier for employers to pay for this benefit and so make fewer of their workers do without? No. Did more Americans manage to buy policies on their own, using the magic of the free market coupled with such conservative panaceas as tax-favored health savings accounts? No.

The government became the insurer of last resort.

Without a boost in Medicare and Medicaid enrollment, the number of uninsured people would have risen once again last year. The Census data show that the percentage of Americans getting their coverage through the government jumped almost a full percentage point, from 27 to 27.8 percent. Most of the increase came in Medicaid, the joint state and federal program that insures the poor. Medicare, which insures the elderly, and Medicaid combined now provide coverage for 81 million Americans.

At the same time, the percentage of people who get private insurance through employers fell again, to 59.3 percent from 59.7 percent in 2006. It's this decline that has driven up the number of uninsured people -- there are about 6 million more uninsured now than there were in 2001. Which means, of course, that in the current economic downturn more people will become uninsured as businesses shed jobs and try to contain their own costs by curtailing coverage. The employer-based health insurance system, for anyone who hasn't yet noticed, is crumbling.

So why would the two presidential candidates seek to build a new system upon such a creaky foundation? There are only bad answers.

To be honest, Republican John McCain would effectively destroy the employer-based system by breaking it up even further, giving individuals tax breaks to buy insurance on their own. It won't work for the simple reason that the whole concept of insurance is based upon pooling risk: Those who stay healthy effectively subsidize those who get sick, and premiums remain lower than they otherwise would be for a sole individual or family. Besides, after years of tax breaks and other efforts to boost the individual insurance market that were put in place by congressional Republicans, the percentage of people who directly purchase insurance on their own also is declining, the Census Bureau says.

McCain at least has a partisan excuse for taking this approach. The free-market ideologues in his own party are convinced of their correctness, even when their faith is easily punctured by facts.

But what about the Democrats? From the start of their primaries, it was clear that the major candidates were too skittish about taking their talk about universal, affordable health insurance to the logical conclusion: that there is no simple or affordable way to achieve this so long as we continue to rely on something that's neither universal nor even predictable -- employment -- as the basis for coverage. All of the health insurance plans outlined by the major Democratic contenders, including Barack Obama, essentially would patch holes in the existing system.