Health Reform on the Table

Almost every American over 65 is covered by Medicare, which functions robustly but needs updating with, for instance, some prescription drug coverage. That was President Bush’s chief topic in a speech last week in Grand Rapids, Mich. Politically, it was the right issue: Seniors vote. The national crisis, however, is in the 41 million people, more than 7 million in California alone, who lack any kind of health coverage.

The number of uninsured is expected to rise sharply this year as deficit-strapped states reduce public insurance and economically at-risk small businesses stop offering coverage. Medicaid, the main federal-state insurance program for the poor, has become the second-biggest drain on state resources, behind education. Every state but one has plans to cut or already has cut the program.

There are pragmatic efforts underway in Congress to stem the problems, though Bush didn’t mention them. On Thursday, two committees in the House of Representatives will begin hearings to seek common ground on short- and long-term ways to strengthen Medicaid and Medicare and reduce the number of uninsured.

The hearings should focus on principles that influential moderate Sen. John B. Breaux (D-La.) sees as the foundation of health reforms:

* Individual responsibility. All Americans should be legally required to carry a basic level of health insurance, just as drivers are required to have auto insurance. Breaux’s goal is to have the federal government define bare-bones medically necessary care and partly or fully subsidize the cost for lower-income people, while discouraging employers from dropping job-based coverage.

Breaux also proposes federal grants to help states create “coverage pools,” similar to some states’ car insurance pools, so that anyone without employer coverage could buy health insurance at group rates. Such steps would reduce per-person health-care costs and lighten the counties’ burden of uncompensated health care.

* Broadly shared risk. All individuals should be guaranteed access to the coverage pools. But the Bush administration would allow HMOs to court the healthiest consumers and refuse coverage to others.

Bush’s speech in Michigan drew unexpectedly sharp criticism from leaders in his own party. Sen. Charles E. Grassley, the Iowa Republican who chairs the Senate Finance Committee, said he would oppose a Bush plan requiring seniors to leave the traditional fee-for-service Medicare system to obtain prescription drug coverage. Sen. Olympia J. Snowe (R-Maine) said she worried that holding up a prescription drug benefit for broader reform of Medicare could delay action indefinitely.

The open dissent within the GOP could be good for achieving reform, not just debating it. Ever since the Clinton health-care plan imploded nearly a decade ago, reforms have been derailed every year by political infighting. Bush should join Snowe, Grassley, Breaux and other health reform moderates to stake out areas of agreement.

With his party controlling both houses of Congress, Bush cannot afford a continuously growing tide of working people with no health care coverage at all in what is still the wealthiest of industrial democracies.