NEW YORK -- Here's a basic truth to hold in your mind, as you watch the health care debate unfold.
A country can provide unlimited care to a portion of the NTC population or limited care to everyone. But it can't provide everyone with unlimited care, because the demand for health services knows no end.
Currently, we provide a lucky 85 percent with what amounts to unlimited care, give or take a few services here and there. An unlucky, uninsured 15 percent get haphazard coverage -- some excellent, some poor -- depending on the doctors and hospitals available to treat them free. If they're not treated free, they get bills that can break them. Sometimes they're blocked from getting treatment at all.
The new system proposed by President Clinton will cover everyone. The question of limits isn't on the table, however, except in minor ways -- and at this point, it shouldn't be. First, a new system has to be up and running.
Then, as its costs and savings become clear, the country will have to start on a second, and equally critical, round of decision-making. Should comatose patients be kept on kidney dialysis? Should $100,000 be spent saving one-pound babies? Should heroic operations be performed on the very old? When families say, "do everything," must the medical system always say yes? If so, costs can't help but spiral out of control -- especially as the boomer generation ages.
Superior medical treatment doesn't create more well people, points out medical ethicist Daniel Callahan of the Hastings Center in Briarcliff Manor, N.Y. It creates more of the sick. First, it saves people who would otherwise die but who cannot be restored to health -- thus raising the number of the chronically ill. Second, it addresses ailments or inconveniences that earlier generations accepted as part of the aging process -- thus raising the potential number of patients.
Rationing is the spook in the closet. In a recent New York Times/CBS News poll, about three-quarters of Americans supported taxes on liquor and cigarettes to help pay for health care. But only 36 percent would be willing to drop expensive treatments that extend patients' lives only for a short time.
Oregon alone has faced up to rationing. After a lengthy period of public debate, it developed a priority list of treatments that, by 1995, must be offered to virtually every state resident. "Must cover" services include everyday preventive care (like mammograms) and treatment to prevent death in patients able to recover. Low on the list, and not insured by Medicaid, are conditions that get better by themselves (head colds, mononucleosis) and conditions where treatment is usually futile (end-stage cancer).
How Oregon's system fits into the Clinton plan remains to be seen. But Congress must make a place for it, as one of the paths toward long-term cost control.
Clinton's vision will be changed but, one hopes, not by too much.
In their competing approaches, the Republicans would order everyone to buy their own health insurance. That seems singularly futile. The working poor would get government aid, but in amounts almost certainly too small. Moderate earners still couldn't afford the likely price. And what happens to people who ignore the law?
This weakness affects part of the president's plan, too. The self-employed have to step forward to pay, unless the IRS can collect their premiums along with their tax.
The Clinton plan doesn't seem to do enough to cure the present system's intolerable bureaucracy.
The cheapest and simplest system would be a national health program under which the government negotiates with doctors and hospitals, and users are taxed, just as Medicare users are taxed. Some day, it will come to that.