As Jonathan Cohn pointed out in the May 1 New Republic, the object of health insurance is to get as many people as possible into one big pool, mixing the sick with the healthy. This way, the healthy pay a little more than they otherwise would, but those who get sick pay a lot less.

Since everyone gets sick eventually, if only from old age, it works out fairly. Your chances of never being sick a day in your life and then dropping dead of an undiagnosed heart condition at an early age are less-than-lottery-slim.

In most advanced countries, this led logically to national health insurance -- everybody in the same pool, only one administrative agency instead of hundreds. But because American insurance companies go batwig at the mention of national health insurance, and because we used to have doctors who insisted that it was "socialized medicine," we could never get it through the political system. In recent years, many of our docs have been radicalized and now even unionized by the unhappy experience of working for corporate HMOs.

As a cancer survivor, I am now part of a network regularly called upon to help raise $300,000 to $400,000 for some individual whose insurance company has found a way to drop her. Always a life at stake. The hundreds of thousands of you who have had your HMOs fold under you know how chancy the present system is.

George W. Bush's solution is to promote medical savings accounts -- MSAs. Individuals buy a cheap insurance plan covering only catastrophic illness and then put money aside, tax-free, to cover their medical bills. If there's any left over at the end of the year, they get to keep it. The theory is that this will discourage people from spending frivolously on health care.

"In reality, MSAs simply allow people who expect to be healthy to opt out of larger insurance pools," said Cohn. "Small businesses like the accounts because they transfer the onus for medical coverage more squarely onto individuals. But most experts who have looked at MSAs have concluded that, by further segregating healthy and sick in the health-care market, they make it tougher for people likely to incur high health-care bills to get insurance."

The other piece of the Bush plan is to set up association health plans allowing small businesses to clump together to buy health insurance as cheaply as the big corporations do.

The Catch-22 is that most states already have small businesses clumped together in an insurance pool. The only difference the Bush plan would make would be to exempt those plans from state regulation -- i.e., requirements for minimum benefits like mental-health coverage.

The result would be further segregation of health coverage -- employees healthy, rates go down; a couple of employees get very sick, rates go up; company can no longer afford coverage, drops policy; end result, more uninsured.

Neither move is going to help the 44 million uninsured in this country, and both are likely to increase their number. This is not a solution. For the uninsured, Bush proposes a $2,000 tax credit per family to allow them to buy their own health insurance -- but $2,000 doesn't nearly cover the cost, and nothing is more expensive than buying health insurance as an individual.

You find the same problem with Bush's plan for prescription drug coverage. Al Gore wants to make it part of Medicare for all seniors. Bush would subsidize prescription drug coverage to some extent for seniors at all income levels and subsidize all drug costs for the poorest seniors (less than $11,300 a year). That plan would force many into the cheapest HMO plans and leave others without coverage for necessary medicines.

In general, you find Gore wanting to build on existing government programs and Bush wanting to turn away from government programs and push health coverage back to the private market, even subsidizing insurance companies.

For those whose faith in the free market is religious, this is not something to debate. But even Adam Smith admitted that the free market can't take care of everything. And one of the things that no country has yet found a way to make it do is health care. The upside to having government as the only insurer is that it's cheaper because profits don't enter into it.

Worth considering, even if boring.

Molly Ivins is a columnist for the Fort Worth Star-Telegram. To find out more about Molly Ivins and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate web page at www.creators.com. COPYRIGHT 2000 CREATORS SYNDICATE, INC.

Email this article to a friend