Healing healthcare

VOTERS IN THE United States rank healthcare second only to Iraq as an issue of concern in the presidential campaign. Close to 45 million people in this country lack healthcare coverage, including 6.5 million in California -- roughly 17% of the state’s population. Increasingly, Americans realize that our healthcare system, which at $2 trillion a year represents 18% of GDP, with spending expected to double by 2016, is probably unsustainable. That adds up to an economic crisis that must command the attention of the 18 candidates with serious aspirations to become the next president.

Today, we begin an occasional series on campaign issues with an examination of healthcare. The challenge for the nation and its candidates starts with two questions: Who should be covered? How can costs be contained?

First and foremost, any healthcare program must extend coverage to everyone. Securing affordable healthcare for all is, simply, the right thing to do. It’s also key to cutting excess costs.

Many states, including California, are already debating universal healthcare. The candidates should build on these efforts by requiring states to devise their own universal coverage solutions. The state-based approach offers room for regional flexibility and allows for innovation, hallmarks of federalism at its finest. But the federal government should not create this mandate without offering guidance and financial support.

As part of its direction to the states, the government should insist that businesses, individual taxpayers and the insured split the cost of coverage. Today, employers are the principal source of health insurance by default. In the future, they should be asked to choose between supplying coverage or contributing to funds that cover the uninsured; they should not have the option of paying nothing.

But paying for insurance and administering insurance are not the same, and businesses should not be the only source for coverage. Here, government may help by creating a system in which many types of insurance providers can flourish. We urge a federal mandate that every state ensure the development of purchasing pools -- sometimes referred to as “insurance exchanges” -- that group healthy and less-healthy people together, making coverage affordable for individuals who aren’t lucky enough to have insurance through their employers. Everyone -- young and old, healthy and ill -- must participate. And providers and insurers should be allowed to compete for patient business.

Next, the candidates must talk truthfully about cutting costs. Vague pronouncements of faith in “market-based solutions” are worthless when there is no rational market at work, and where accurate pricing information is scarce. Prices in medicine are determined not by supply and demand but by a scrum of market forces including insurers, doctors, employers and government -- and, rarely, consumers. As a result, a procedure that costs a patient with insurance $1,000 can cost an uninsured patient a dozen times that. Hospitals and medical practices tailor offerings to maximize reimbursement from insurance companies and Medicare, not necessarily taking into account what most helps patients.

Candidates of both parties are advocating improving preventive care and modernizing medical computer systems to save money. Democrats such as Sen. Hillary Clinton have done one better by calling on the federal government to set up an independent -- not industry-backed -- institute to study medical outcomes and write guidelines to help insurance companies, hospitals and doctors push the most effective and cost-efficient treatments. Such measures, too, should be a part of the federal mandate to states.

The cost question is a painful one because it inevitably leads to the question of sacrifice. If everyone is going to be covered, every treatment probably won’t be. Clear conversation on this, however, begins with the recognition that this country already rations healthcare -- those without insurance routinely go without care.

The complexity of the country’s healthcare crisis makes it difficult to debate in the rapid-fire exchanges that too often characterize our modern political campaigns. So it is all the more important that candidates present substantive proposals. America has a chance to grapple with this fundamental issue now. If we succumb instead to slogans, we will long regret it.