COLUMN ONE : A Queasy Feeling on Health Care : People want the system fixed--but there’s no agreement on how. Even in Pennsylvania, where reform was a winning election issue, there is as much confusion as fear.

The nation’s health care dilemma caught up with Scott Rodger the way it has for many Americans, barely noticed at first, now a gathering preoccupation.

As long as he had work, there was little reason to concern himself with the medical benefits that came with his job as a physical therapist for the mentally disabled. It was only after Rodger was abruptly let go last January, and his coverage stopped, that he began to worry.

One gray, rain-swept winter’s morning, Rodger drove to a Pennsylvania employment office to apply for state medical aid to replace his lapsed insurance. The clerk who interviewed him was properly sympathetic, sighing as she shuffled paper and computed his dwindling finances. Then she came to the point. His pregnant wife and year-old daughter qualified for state health assistance. Scott Rodger did not.

Outside the office, Rodger dragged on a wet cigarette, rain beading on his doughy face. “If I get sick, it’s either ride it out on my own or spend money I don’t have,” he said. “Great country we got.”

Americans are openly troubled by the state of their health care system. They have become frightened by its growing lack of affordability, insecure about their access to quality care, nostalgic for the vanishing family doctor. And yet, confused and alarmed by the scope of the system’s problems, they are ambivalent about solutions. In an election year already dominated by a lingering recession, voters’ most intimate anxieties about their own health are being sharpened by doubts about the cost and availability of medical care.

Hard times have served as a psychic tripwire, setting off tiny implosions of fear with each new act of belt-tightening. A million people lost their jobs and medical benefits in the past year’s economic downturn, swelling the ranks of those without medical coverage to 37 million. In Bethlehem, as in any American town, every time someone is laid off, every time a business shifts more of its health costs to workers, every time a union strikes to protect benefits, the safety net seems to fray a bit more.

“The consequences of the failure of our health care system has finally penetrated the mainstream,” says Dr. Irwin Redlener, a pediatrician and an official of the National Health Policy Council, a reform advocacy group. “People are worried about rising costs. And anyone scared of losing their job is just as scared about losing their health benefits. This is our wake-up call.”

In a 1990 survey by The Times Poll, 36% of Americans answering a battery of questions on health care issues said the entire system needed fundamental change. By early this year, a national poll conducted by the Washington firm of Mellman & Lazarus for the Health Insurance Institute of America found that 41% thought significant changes were needed and another 26% said the health care system is “beyond repair and needs to be rebuilt from scratch.”

Talk is rife in political circles that health care could play a role in steering presidential choices this year. In recent national surveys and exit polls conducted during primary elections, health care often ranked second to the economy among issues crucial to voters.

Some observers point to the heightened role that health care reform played in the Pennsylvania Senate election last fall, helping to win a seat for Democrat Harris Wofford, as evidence that presidential candidates might harness the debate to their advantage. Wofford’s insistence that “if criminals are guaranteed access to a lawyer . . . working Americans should be guaranteed access to a doctor,” has become a catch phrase among Democratic Party regulars who see health care as this year’s golden-egg issue.

But the very complexity and remoteness of the health care discourse muddies its political usefulness. In this spring’s early presidential primaries, Democratic candidate Bob Kerrey tried to follow Wofford’s lead, spending much of his time promoting his detailed national health plan. But among a crowded field of candidates all touting health care reform, Kerrey could not connect with voters, despite--or perhaps because of--his single-minded emphasis. Kerrey, a senator from Nebraska, dropped out of the race in March.

“What we learned,” says Mike McCurry, a senior adviser to Kerrey before he left the race, “is that you have to tap into frustration with the current system and follow the Wofford model--that is, enunciate general principles rather than a specific plan. Voters don’t seem to want specifics, but someone who will lead them. The mistake we made in laying out a detailed plan was that voters were clearly able to decide what they didn’t like about it.”

In Bethlehem, a cross section of two dozen families were quick to speak of the fears that helped lead to Wofford’s victory over former U.S. Atty. Gen. Dick Thornburgh. But they grew tentative as they grasped for answers.

When David and Elaine Harshberger and her two sisters, Diane Dalhe and Lisa Warner, and Warner’s husband, David, gathered around the Harshbergers’ dining room table to sort out their opinions on health care, they were unanimous on what was needed.

“There should be quality health care regardless of anybody’s ability to pay,” Elaine Harshberger said.

But when it came to deciding how it should be done and who should pay for it, their ideas were as diffuse as the cigarette smoke that curled lazily over their heads.

“I’m going with the Democrats,” said Lisa Warner. “Bush is fine for foreign policy, but he’s not taking care of us at home.”

“He’s an easy person to blame,” said her husband, David Warner. “I haven’t heard anything from Democrats that makes any sense either.”

An ABC News/Washington Post poll in January showed only 29% trusted Bush to “do a better job on improving the health care system”; 60% put their faith in the Democratic majority in Congress.

Health care might influence Alane Nebbia’s vote this fall if she hears from a candidate who spells “it out for me in a way I can understand.” But, like many Americans, the 30-year-old suburban Bethlehem woman feels lost amid the Hydra-headed complexity of the debate. “Whatever makes sense, I’ll listen to,” she says, exasperated. “Just convince me.”

For the time being, Nebbia, who is starting a word-processing business in her new tract home, and her husband, Mark, 31, a Trans World Airlines pilot, are far from harm’s way. But with TWA now in bankruptcy, she worries about what might happen if he loses his job. She could easily return to her old position as a personnel assistant on Wall Street, where health benefits are standard. But she would pay a personal toll--and the return to her wearying two-hour commute would be the least of it.

“If I go back to a full-time job, we’d have to postpone starting a family,” Nebbia says. “It’s like, great, we could keep health costs under control, but look at the price.”

Medical expenses are comparatively moderate in Bethlehem, a 201-year-old community that began as an enclave of Moravian settlers, thrived as a steel town and now struggles to overcome the industry’s shakeout and diversify its financial base. Health insurance that costs a family of four $8,000 a year in New York is $4,500 to $5,000 here. Hospital stays are about $100 a day less than in Philadelphia, an hour to the south.

At least seven hospitals are within driving distance in the surrounding Lehigh Valley, a fast-growing swatch of Pennsylvania hill country that became a bedroom community in the last decade for thousands of Philadelphia, New Jersey and New York commuters.

But like so many larger cities, Bethlehem has begun to show signs of its own health care crisis. The town’s moderate medical costs have begun to climb ominously upward. In the year ending March 1, 1991, health expenses in Bethlehem jumped 8.9%, outstripping an 8% rise nationally, says Kamran Afshar, a local economist. “It appears that doctors and hospitals are trying to catch up.”

The city was already shaken by a decade of layoffs at its biggest employer, Bethlehem Steel Corp. Now it reels from a widespread recession that has spread like a contagion from large firms to smaller businesses--reminding all but the very rich that health care comes with no guarantees.

“We’re not the only ones suffering anymore,” says Ben Boylston, Bethlehem Steel’s vice president for human resources. “There are small companies in this town seeing jumps of 30% to 40% a year in their coverage costs.”

In 1989, Bethlehem Steel’s health care expenditures totaled $165 million. Last year, they rose to $222 million. The firm has experimented with familiar cost-containment strategies, revising benefit plans, raising workers’ deductibles, adopting a tough case-management approach to oversee employees’ medical choices. But there are no silver bullets.

“These measures slow down the rate of increases for a while,” Boylston says. “Then, after two or three years, we get socked again. It’s a no-win game.”

Roy Christ, 40, once earned good money at Bethlehem Steel--before the recession and stiff competition decimated its work force from 20,000 a decade ago to 4,000 today. A tired-eyed man with shoulder-length gray hair and a gray beard, Christ spent 10 years on the line as a crane operator before he was laid off in 1983. Forced to take a low-wage job as a dog groomer, he made a few feeble stabs at paying for his own medical insurance but gave up.

Then last December, Christ took a step outside the front door of his townhouse. He slipped on a patch of ice and cartwheeled down the front steps, breaking his ankle in two places. At nearby Muhlenberg Medical Center, an X-ray technician told him he would have to be admitted. When Christ balked, the technician said flatly: “Too bad, this is a medical decision.”

Doctors inserted a steel plate and nine screws in his ankle. Christ stayed in the hospital six days and came home in a thigh-high cast. In the following months, he paid only for a $15 cast shoe. But bills covered with small type soon began arriving regularly. Christ owed $7,000 in medical bills--more than he takes home from his $10,000 annual salary as a dog groomer.

Now, back at work on crutches, he learned recently that the state will pay for his operation. But Christ soon starts three-day-a-week therapy sessions without knowing how he will pay for them.

“My attitude is, if you get sick, you shouldn’t have to worry about costs,” Christ says. “We need some kind of national program.”

Princeton sociologist Paul Starr, who charts the social transformation of medicine, believes that in addition to their own experience, voters form opinions on the “possibilities that are held out to them.” For that reason, Starr says, people like Christ could be receptive to a political leader who spells out an attractive vision of an altered American health care system.

“The public needs to know only what a candidate’s broad commitments are,” Starr says. “You can’t expect the details of health care reimbursement to be dealt with during an election. Policy isn’t made in elections. But policy directions are.”

Others, such as Robert J. Blendon, who heads the Department of Health Policy and Management at the Harvard School of Public Health, see avoidance in Christ’s fuzzy demand for change. Americans, Blendon says, have yet to squarely confront the critical details of the health care debate.

“What is at stake are root-canal solutions and Americans don’t want to take them,” Blendon says. “They know what they don’t want to do. But they don’t know what they want to do.”

Rose Staats, 34, a housewife who is rearing two daughters with her husband, Bruce, 39, a salesman for an environmental products company, is not keen on “the idea of having a socialized system.” Like many Americans, she worries that a government system would lead to rationed care, forcing her to travel farther for treatment and endure long waits for appointments.

But she is unable to identify any program that she believes might bring medical costs under control. “All I know is it just has to be reformed,” she adds.

Without a clear direction from voters, government dithers. The Congressional Record bulges with health care proposals. President Bush favors a classic Republican approach that would provide tax credits to help families without medical coverage buy insurance, nudge Americans into health maintenance organizations and use private-sector reforms to streamline the health care system.

Democrats offer plans that would give the federal government a stronger role. Some legislators back an approach similar to Canada’s system, in which government would provide tax-supported health care to the entire population and regulate costs. Another solution, backed by many labor and business groups--Bethlehem Steel among them--is “pay or play.” It would give companies the choice of buying health coverage for their employees or contributing to a government-backed health plan.

Edward Howard, executive vice president for the National Alliance for Health Reform, likens the current inertia in Washington to the paralysis that gripped the capital in the immediate years before the enactment of the Social Security Act of 1935 and Medicare in 1965.

“The pressure has been building; the ice has built up behind the dam,” Howard says. “Americans clearly want something done. The question is, will this election produce the kind of leadership that can bring about major reform before the dam bursts?”

As the election approaches, a growing subset of working poor and lower-middle-class Americans faces life without any immediate prospect of obtaining health coverage. In many states, workers like Roy Christ do not make enough money to buy their own insurance but are too well-off to qualify for government programs.

Dan Hawkins, an analyst for the Assn. of Community Health Centers in Washington, says that in every state but California, many families making less than the federal poverty level--$12,500 a year for a family of four--are prevented from obtaining Medicaid and other government health benefits. Only pregnant women and children younger than 7 are exempt from those limits, Hawkins says.

The strictest guidelines are in Alabama, where a family of four is unable to qualify for Medicaid if they earn more than $4,400 a year. In Pennsylvania, families are disqualified if they make more than $8,124, which is why Roy Christ was unable to get benefits. In California, the cutoff is $14,220.

In Pennsylvania’s Lehigh and Northampton counties, an estimated 44,000 people scrape by without health coverage--Scott Rodger among them. His then-pregnant wife, Joyce, 23, and their 1-year-old, Jennifer, qualified for Healthy Beginnings, a Pennsylvania medical program targeted at mothers and children, which his newborn daughter, Christina, qualifies for as well. Joyce will be covered until Christina turns 1. But Rodger has no coverage.

Fired from his $17,000-a-year job with the state of New Jersey for, he says, taking too much time off after his wife broke her ankle, Rodger was suddenly faced with $2,000 in medical bills. He owed most of the money for renting a heart monitor to guard against Jennifer’s sleep apnea, a respiratory condition she has had since birth. She stops breathing and must be awakened to survive. The state has agreed to pay half of the expenses, but Rodger is liable for the remaining $1,000.

“Last year, I’d be watching TV and hearing about guys like me on the news,” says Rodger, who rents an apartment in the blue-collar suburb of Hellertown. “I never realized how quickly it can fall apart.”

In January, when The Times Poll asked a national sample of Americans to identify the root causes of the health care crisis, 39% cited malpractice suits, 34% blamed it on doctor’s fees, 32% identified hospital costs and 24% targeted inadequate cost controls.

The causes, in fact, are legion. Less obvious factors include spiraling costs for new medical technology, inadequate government reimbursement to hospitals for treating indigent patients and those on Medicare and other health programs, and cost-shifting by hospitals and doctors--charging some patients more to compensate for others who cannot afford to pay.

Experts say that differences in economic standing also affect how Americans perceive the causes and effects of the health care crisis. A 1991 national survey found that satisfaction with the health care system’s cost and quality was highest among those earning more than $50,000 a year and lowest among those making less than $12,000.

Neil and Beverly Johnson, who live in a hillside Colonial home in Oakland Hills, one of Bethlehem’s most exclusive neighborhoods, have little to complain about in terms of their own health care costs. Neil Johnson, 46, an AT&T; project manager who makes more than $60,000 a year designing telephone systems, calls his company-paid coverage a “good plan.”

Until two years ago, AT&T; paid for everything but doctors’ visits and prescriptions--expenses that the upper-middle-class Johnsons could easily afford. In 1990, the company put a cap on its expenditures and began offering HMOs to its employees to hold down costs. The Johnsons decided to join.

“In a perfect world, we could still go to our old doctor,” Neil Johnson says. “But the HMO is fine for our needs.”

Beverly Johnson agrees. But the Johnsons are divided over what should be done to alleviate the nation’s health care crisis.

Neil Johnson wants to see reforms within the nation’s market-driven health care system.

Beverly Johnson, on the other hand, is part of a sizable, but shrinking, third of Americans who think the health care system requires no tinkering. “Never has a country had so many resources at its disposal,” she says. “If a family goes out and buys a color TV and then they tell me they can’t put fillings in their kids’ teeth, I won’t accept that.”

Although some poorer Americans may neglect their families’ health care for instant gratification, most, insists Allentown patient advocate Charles Inlander, are simply faced with the fundamental quandary that confronts people like Scott Rodger. They must choose between health coverage and “rent, utilities, car payments. Do you just let all that go so you can have insurance?”

Health care policy experts say misinformation often clouds the debate over medical costs. Nat Gencarelli, a history teacher at Liberty High School in central Bethlehem, subscribes to perhaps the most widespread stereotype--that of the overpaid doctor. In a 1990 Times Poll, 43% of Americans contended that their physicians earned more than they deserved.

According to 1991 statistics compiled by the journal Medical Economics, the American physician nets a median annual salary of $141,720.

The figure astounds Gencarelli, who just began making $40,000 a year at age 47. “It just seems that years ago, doctors were middle class like me,” he says with a trace of bitterness. “Now they all seem to be driving around in Mercedes and living in the biggest houses in town. It’s like they all have to make their fortune in the first few years out of medical school.”

Dr. William Reppert, 68, winces at the familiar stereotype. A soft-spoken internist who likes to think of himself as the embodiment of Gencarelli’s vanishing family doctor, Reppert’s annual income has never approached $141,720.

“My practice could have never supported those kind of fees,” says Reppert, who is now semi-retired. The former director of medicine at St. Luke’s Hospital, he still sees patients in an old stone house in Fountain Hill, a blue-collar suburb where he began a family practice in 1952 and reared four children.

But when he hears people talk of reining in physicians’ pay and dismissing younger doctors as money-grubbers, Reppert bridles. “Those who say they’ll fix those rich doctors and those uppity hospitals are practicing demagoguery,” he says. It is the “affluence in the medical system,” he adds, that “attracts creative people.”

Despite the inertia in Washington and confusion among voters, Reppert has already reconciled himself to change. “I just hope that when change comes, it’ll be done in a way that won’t destroy a pretty good system.”