The Patchwork Monster

At dinner, two sets of parents of college seniors are discussing their dreams for their soon-to-be newly minted graduates. Doctor? Lawyer? Scientist? Entrepreneur?

''I just hope she gets a job with health insurance," says one mom, breaking the spell. ''The insurance cuts off the day they graduate." A dad chimes in: ''COBRA coverage costs over $400 a month." (COBRA is an acronym for a consolidated budget act that allows you to keep your coverage by paying the premium costs out of pocket. It is well named.)

In a country with a rational system of health insurance, your coverage would not be subject to the quirks of when you graduated college, where you worked, or whether you had been sick earlier in your life. But the American system is a patchwork mess of coverage, noncoverage, and inadequate coverage, slightly tempered by well-intentioned efforts to fill in the cracks, which only add to the fragmentation and cost.

Meanwhile, George W. Bush's budget proposes to cut some $45 billion out of Medicaid funding over 10 years. The Massachusetts share of the loss would be $1.26 billion.

Medicaid is becoming the monster that's devouring the rest of state budgets. In recent years, Medicaid costs have been rising at between 9 and 12 percent while state budgets are just about keeping pace with inflation.

But Medicaid costs are rising not because states are becoming more generous with what they cover or because states are liberalizing Medicaid eligibility rules. On the contrary, rules are being tightened and coverage restricted. The Urban Institute finds that actual Medicaid per-patient costs are growing at only about half the rate of private insurance, and a study by the Kaiser Family Foundation reports that 23 states have already taken actions to freeze enrollment or cut benefits.

So why is Medicaid such a drain on state treasuries? Because it is the health insurance of last resort. As fewer employers provide coverage that employees can afford, more and more people are being dumped into the Medicaid pool, leaving states holding the bag.

Not content to cut the federal share, Bush also proposes to turn the program into a capped block grant, which would pass even more of the costs to the states. This, in turn, would lead to even further benefit cuts and more people going without basic medical care or flooding emergency rooms.

Another government health program, the State Children's Health Insurance Program, was intended to cover kids whose parents made a little too much money to qualify for Medicaid. There are millions of families where one or both parents have inadequate employer-provided insurance or no insurance and the kids are covered under SCHIP. And because parents' income fluctuates, kids can be bounced from program to program -- SCHIP, Medicaid, private insurance -- with different eligibility rules and different doctors.

Continue the tour of our absurdly fragmented health system. As part of the same 2005 budget proposal, the president admits that his crown-jewel program, drug coverage under Medicare, will cost not the $400 billion over 10 years that he projected when he jammed the bill through Congress in 2003 but $1.2 billion. Bush officials helpfully explain that with changes in various formulas -- in other words, benefit cuts -- the cost can be held to a mere $720 billion.

The Medicare drug law, which doesn't even become effective until 2006, is so outlandishly expensive because it was written to drug industry specifications. The law explicitly prohibits the government from negotiating bulk discounts with drug companies the way VA hospitals and the Canadian national health insurance program do. Seniors covered by Bush's Medicare drug program and their partner, the American taxpayer, will pay sticker price.

Gentle reader, this is all insane. We have the world's most expensive medical system and the least reliable insurance coverage. Yes, I know Clinton-care was a political disaster, but it wasn't true national health insurance. Bill Clinton naively tried to give the insurance companies a big piece of the action, and they gratefully responded by spitting in his eye.

Ordinary people are absolutely sick of the health insecurity and the endless and wasteful paper chase. So, by the way, are doctors. We have what the political scientist Walter Dean Burnham calls a ''politics of excluded alternatives."

Senator Ted Kennedy in his January 12 National Press Club speech actually called for “Medicare for All.” He deserves the broadest support. It's called leadership.

Robert Kuttner is co-editor of The American Prospect. This column originally appeared in the Boston Globe.

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