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National reform needed Growing problems in cost, coverage demand changes in health insurance

Last of six editorials

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With apologies to Winston Churchill, health insurance in America is an accident wrapped in a puzzle inside a contradiction. That is hardly a comforting configuration when your solvency -- or your life -- depends on its functioning.

That health insurance works as well as it does is testament to many factors, including the inherent strengths of capitalism, but something is fundamentally amiss when good health is an unspoken condition of access and illness can result in forfeiture. This isn't merely a case of putting the cart before the horse, it's driving the cart right over the beast.

But such is the case with the peculiarly American system of employer-based health insurance. To have it, you must be healthy enough to hold a job. To keep it, you must not get so sick that you can't work.

That's an oversimplification, since a working spouse can cover an unemployed mate, but the nut of it is painfully and preposterously true. If you get so sick that you can't work, you can lose the insurance you now need more than ever. Without access to affordable care, you may lose the chance to regain your health and return to work. The slide can be swift and calamitous, ending in financial ruin, premature death or both.

That's only the worst of the conundrum of employer-based health insurance, but there is plenty more undermining its foundations. Two recent reports produced by or published in respected sources -- The Commonwealth Fund and the Journal of the American Medical Association -- argue that not only is the American health care system inefficient, it's "a dysfunctional mess" and the worst among wealthy nations for providing quality, access and efficiency.

Starting last Sunday with an overall analysis and the first of six editorials on what is fast becoming a national health insurance crisis, this page has examined both the problem and some proposed solutions. Fixing this crumbling system is critical, and the time to move is now, as states turn their attention to the problem and a presidential campaign takes shape with health insurance among the top domestic issues.

Many states, including New York, already are moving ahead with plans to provide insurance to more residents, and while those efforts are important, especially in the absence of federal action, in the end they can amount to nothing more than 50 fingers in a bursting dike. They leave in place most of the problems associated with employer-based insurance, create a confusing mash of parallel health systems that discourage mobility and, assuming they have limits similar to existing private-sector plans, still leave residents exposed to financial ruin.

The best solution would be for Washington to muster its nerve and craft something new: a national system that provides portable coverage to all Americans and shields them from the economic ravages of catastrophic illness. It should emphasize disease prevention, healthy living and careful management of chronic conditions such as diabetes.

Such a plan need not simply replicate the Canadian or British systems. Indeed, it should seek to account for their weaknesses, which can include long waits for certain procedures. Accomplishing that -- and controlling expenses, a crucial need given the excessive costs of this country's health care system -- almost certainly means preserving key elements of competition within the medical and insurance systems. Whatever system may be developed must reward efficiency.

No system will be ideal. There will always be trade-offs, just as there are now. The trick is to make those compromises palatable, a task that will be difficult but should be made easier by this glaring fact: The country's existing system is bloated, inefficient, exclusionary, expensive and broadly dysfunctional.

That doesn't mean that anything would be an improvement, and government has an discouraging history of packing important programs with special-interest goodies and a smorgasbord of unintended consequences. But the current system is so bad that careful lawmakers have a lot of room to craft something that is vastly better.

More to the point, the current system is so bad that they have no other responsible choice.

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