WASHINGTON -- It is possible to date precisely when health care reform made the critical transformation from public preoccupation to political priority: Nov. 5, 1991.
That was the day Harris Wofford, an old-style liberal Democrat, got his marching orders from voters in Pennsylvania to deliver a message to Washington. The message in his own words: "We have a health crisis that is bankrupting workers, families, our companies, our whole economy."
So clearly was it delivered by Mr. Wofford's upset U.S. Senate victory over high-profile Republican Richard L. Thornburgh, former U.S. attorney general and Pennsylvania governor, that President Bush took immediate notice and ordered his experts to produce a health care reform package.
Mr. Bush, by all accounts, had hoped to avoid the health issue until after the coming election. After all, Michael S. Dukakis, his Democratic opponent in 1988, tried to make health care reform a major election issue. Four years ago, it failed to play.
But this year has proved different. The message from Pennsylvania persuaded the Democrats as well as the president that health care was ready for a new political airing, and the battle was quickly joined.
The middle-class recession, with its twin specters of unemployment and accompanying loss of benefits, added dramatically to the growing dissatisfaction with a health system that costs 13 percent of gross domestic product but leaves 13 percent of the population uncovered, and that can put even those with insurance in financial jeopardy.
The nation's health care bill is staggering: almost $738 billion in 1991, funded by the federal government ($215.7 billion), state and local government ($101.4 billion) and private insurance and outlays ($421.1 billion). In 1960, the national health expenditures were 5.3 percent of gross domestic product; by the year 2000, they are projected to be 16.4 percent.
Together they will surpass Social Security as the single largest component of federal spending by the year 2000. The Medicaid bill will have increased from $14 billion in 1980 to a projected $84 billion next year -- a 600 percent jump. Medicare costs will increase from $43 billion in 1980 to an estimated $131 billion next year, a 300 percent jump.
Trying to get a handle on such runaway programs, along with skyrocketing hospital costs, is hard enough. But beyond the statistics there is a human equation: The more advances medical science makes, the longer people live; the longer people live, the more it costs to keep them healthy; the more it costs, the less the nation can afford it; the less the nation can afford it, the more people are left without health coverage.
An estimated 35 million Americans are without health insurance, 600,000 of them in Maryland. This does not mean they cannot get medical care. Federal law prohibits any hospital from refusing to treat emergency patients, and Maryland has its own hospital treatment guarantees.
"We have national health insurance in this country. It's just that you have to enter it through the emergency room, which is not a very good way to do it," said Mark V. Paul,chairman of the Department of Health-Care Systems at the Wharton School, University of Pennsylvania.
The uninsured generally forgo cost-effective primary or preventive care, constantly have inferior access to attention and usually receive less treatment. A University of Pennsylvania study found that the uninsured receive between two-thirds and three-quarters of the care given to an insured patient.
Maryland's health secretary, Nelson J. Sabatini, said that treating the uninsured is one of two major health-care problems facing the state; the other is rising medical costs.
Maryland is doing a "good deal" to restrain costs, he said, but "hospital costs are going to continue to grow as a result of bad debts and the charity care that is being provided. The answer to that is going to be insuring the uninsured."
On escalating costs, he noted that Medicaid has risen from $450 million a decade ago to a projected $1.9 billion in 1993. Of Medicaid outlays in the state, 70 percent went to long-term treatment for the chronically sick, with 5 percent of Medicaid recipients using 50 percent of the funds.
"Most of the money is being spent on paying the bills for very sick people who need care in very expensive settings," Mr. Sabatini said. "The key to any kind of cost containment is going to be some kind of system that has its emphasis on low-cost, up-front [primary and preventive] care. That is the direction we have to start moving in as a nation."
The presidential candidates have all attempted to address the health care crisis, advancing a variety of ideas for expanding access and restraining costs.
"The problem with all the proposals is either the bill is too high or the effect is too limited," said Wharton's Mr. Paul. "What we have seen over the decades is these various proposals kill each other off because the ones that are feasible are imperfect and the perfect ones are infeasible."
The health care debate this year focuses on three basic approaches:
* An improved private insurance system with greater access for all.
* A mixture of private and public provision, popularly called "play-or-pay," under which employers would either pay health insurance premiums or contribute to a public health care fund.
* A universal national health system operated by the government and financed by taxpayers.
On one thing all the candidates agree: Every American should have access to adequate health care. They disagree over whether it should be financed out of tax funds, administrative efficiencies, corporate finances or private pockets.
"I think the key question to ask is whether particular candidates and their approaches are prepared to take on the special interests," said Ron Pollack, executive director of the Washington-based lobbying group Families USA, identifying the insurance industry, for-profit hospitals, drug companies and hospital doctors as among the "special interests".
"These special interests literally spend millions and millions of dollars each year to try to defeat necessary reform. There is no free ride on it, and that is why this issue has been such an intractable problem," said Mr. Pollack, adding that Mr. Bush's health care reform proposals, based on federal health insurance credits and greater efficiency in the delivery of care, were only "tinkering around the edge" of the problem.
He credited Arkansas Gov. Bill Clinton and Nebraska Sen. Bob Kerrey with being prepared to confront the medical establishment. Both, he noted, favor a national health budget that would crimp the health industry's ability to charge what the market will bear, and both would provide public coverage for long-term health care, which currently bankrupts many families.
Mr. Clinton, who proposes the "play-or-pay" mix, would have insurance companies set premiums using a community rate -- as with automobile insurance -- rather than an individual rate, and would impose uniform pricing on medical treatment.
Mr. Kerrey proposes a national health system to be paid for out of the current funding for Medicaid and Medicare, which would be subsumed into the national system, and through a new federal payroll tax, paid mainly by employers.
In Congress, there are also moves afoot on health reform; but despite all the campaign rhetoric, only limited insurance reforms are expected to emerge this year.