The real issue is that costs are rising so fast that the burdens are growing unbearable for employers and employees. Controlling costs will require many steps, including slowing the rise in prescription drug prices. But most experts agree it won't be possible to restrain health-care costs without significantly reducing the number of uninsured.
There's no shortage of ideas for how to do that. But the real question in all of them is the bottom line: Who pays?
In the last few months, at least three distinct answers have emerged.
As he prepares to leave office, Gov. Gray Davis recently signed legislation that would impose the burden overwhelmingly on the businesses that don't now provide coverage. The measure would require all firms in the state with 50 or more employees to cover their workers, or pay into a state fund that would provide insurance.
Reluctant to instigate such a political showdown with business, the Democratic presidential candidates are pushing plans that mostly would use taxpayer money to cover the uninsured. The most extreme example is the plan from Rep. Richard A. Gephardt of Missouri to provide employers a generous new tax credit to cover most of the cost of insurance. Gephardt's plan not only rejects any new cost to businesses that don't provide coverage today, it shifts to government, through the tax break, roughly one-quarter of the cost now paid by employers who do cover their workers.
Bush's approach looks largely to the uninsured to meet the cost. He's proposing a tax credit that low-income families without insurance could use to help buy coverage. But it would generally cover only half of their cost or less.
Each of these approaches has flaws. Bush's plan asks the uninsured to bear such a large burden that few could afford coverage even with the credit; the best estimates are that Bush would reduce the number of uninsured by less than 10%. The plan from Gephardt (and to a lesser extent, proposals by his Democratic rivals) could impose unsustainable costs on the federal treasury. And the California legislation probably asks too much of the low-wage employers who don't provide coverage, especially at a time when the economy is slow.
The answer is a more equitable sharing of the bill between government, employers and individuals. One guidepost should be the existing division of the tab: Today, individuals and government both contribute about one-third of the nation's $1.6-trillion health-care bill, with employers chipping in about one-fourth and foundations and charities the remainder, according to analysis by Emory University's Kenneth E. Thorpe.
