COST OF HEALTH; U.S. NEEDS TO RETHINK INSURANCE FOR EVERYONE.

Byline: Robert E. Tranquada

IN 1993, when the Clinton Health Security Act was first proposed to provide universal health insurance coverage, there were 37 million uninsured in the United States on any given day. Today, six years later, the number of uninsured is 43 million and growing, and during the year a total of more than 60 million Americans will be uninsured at some time.

Nationally, 16 percent of the population under 65 is uninsured.

One of the most potent arguments used against the Health Security Act was that we could not afford the cost of insuring everyone in the United States. Today, we find ourselves with a huge federal budget surplus and indications that such surpluses will continue for some time. It is time to reconsider the problem of the uninsured.

Let's ask three questions: Who are the uninsured? Does it make any difference to be uninsured - both to those who are uninsured and to all of us? What would it cost to provide coverage universally?

Who are the uninsured? Being uninsured is not an unemployment issue. More than 80 percent of the uninsured are either employed or are the dependents of employed people and a substantial proportion are children. The largest proportion of the uninsured are the working poor. Small employers can no longer afford health insurance for their employees. Large employers are increasingly hiring temporary and part-time workers, for whom no fringe benefits (including health insurance) are required. Minimum-wage earners cannot hope to afford the cost of individually purchased health insurance.

The state plan enacted five years ago to allow small employers access to reasonably priced health insurance has insured about 150,000 of the more than 3 million workers who are uninsured. A small proportion of the uninsured are the unemployed, but the vast majority are working.

Does it make any difference to be uninsured? Absolutely. The uninsured receive less medical care and poorer quality care, are hospitalized more frequently for illnesses that should be cared for out of the hospital (for example, asthma or diabetes), have higher mortality rates and do not receive many basic preventive measures.

They also crowd our hospital emergency rooms, which are required to evaluate and stabilize any person who shows up without regard for ability to pay and substantially increase the cost of care to those who do pay. It is these burdens of uncompensated care that threaten the viability of our emergency care and trauma system for every one of us. The uninsured also transmit untreated and sometimes dangerous infectious diseases, such as tuberculosis, to others. Insurance makes a difference, both to the uninsured and the rest of us.

How much would it cost to solve the problem? If we were to buy a group health insurance policy for 98 percent (in every society there are 1 or 2 percent who remain out of the system) of the currently uninsured, the total annual cost would be about $40 billion per year for the nation. However, we know that 40 percent of the care now being received by the uninsured is already being paid for by them in cash. We also know that if 40 million more people were covered, many costs borne by all the rest would be eliminated, and because those now uninsured would get earlier care for serious disease, those costs would actually be less.

So the real additional cost would be in the order of $15 billion to $25 billion a year, depending on what system were put into place.

Our recorded federal surplus of $70 billion for the year just passed an estimated surplus of $76 billion for fiscal year 1999 and projected $2 trillion surplus over the next decade, make the needed expenditures appear trivial.

In 1998, it is estimated that we will have spent in excess of $1.1 trillion on health care in the United States. The addition of an additional $25 billion (about 2 percent) to achieve universal access to needed health care would be barely noticeable.

The United States spends more money per person on health care than any other industrialized nation in the world - almost double the average of other industrialized countries. Yet we are the only industrialized nation in the world that does not have universal access to needed health care.

And we pay for it. We are 23rd among all industrialized countries in infant mortality and 70th in life expectancy at birth. It is an ugly, embarrassing and unnecessary price to pay. It is time to correct this enormous fault in our society. We cannot afford to let the opportunity get away.