Health care: at the very least.

Walter Shapiro has memorably summarized the collective amnesia of institutional Washington by noting that anyone who can recall what the White House was doing last year is considered a historian, while anyone who can remember all the way back to the Eisenhower administration is "viewed as grasping the full sweep of human history." Just two years ago health-care reform seemed to be the dominant question of American domestic politics. Now it's forgotten. It ought to become a major campaign issue again.

As the Clinton reform effort gathered steam in 1993, one worry among those of us who favor a national approach to health care was that the middle class would be well-served by badly needed insurance reforms, while the poor and the medically indigent would end up ignored. How I wish, today, that fear had come true! Nothing was passed, not even boons to the middle class. These reforms included "portability," which would guarantee that workers who change jobs can retain their insurance; a ban on refusing to insure those with pre-existing conditions; some form of across-the-board pricing in order to reduce the premium penalty on the self-employed and small entrepreneurs; and a rule that would require insurers to offer comparable packages and disclose statistics--thereby enabling health-insurance buyers to make meaningful comparisons between plans. It was assumed that once the Hillary-Ira master plan collapsed, these secondary reforms (commonly labeled "the Bentsen plan," after the former senator) would be an automatic yea vote.

Today, with Bill Kristol and others having done such a swell job of making health-insurance reform seem a near-communist idea, there are no major initiatives in Congress to pass anyhting like a Bentsen plan. And none of the 1996 candidates is pushing such a plank. This is amazing, given that insurance loss in job changes, preexisting condition clauses, and similar flaws in the health-coverage system impact millions of middle-class, voting, campaign-donating citizens--exactly the sort of people whose concerns normally take political priority.

How is it that removing the catch-22s from health insurance has become a non-issue in the 1996 campaign? Kristol and other snug Republican leaders who themselves hold gold-plated medical insurance may not care how many millions of the poor or working class are screwed by health-coverage problems, but middle-class Republican constituents are being screwed, too, if they change jobs, start a small business, or have the temerity to get sick.

Even in a pure-market system, the case for general insurance reform is clear. For example, refusing to provide care to those with "preexisting" conditions makes perfect sense for individual insurers but is nonsensical for society as a whole, as it guarantees that lives will be ruined by medical bills. Yet any individual insurer that chooses to accept the already sick is played for a sucker under the current system, since competing insurers that won't take the sick will have higher returns. The equitable solution is for government to say that insurers who wish to be in the health business must offer a standard basic policy to all comers, regardless of condition. Virtually all health-care analysts, even those fiercely opposed to a national health system, agree that changes like these are needed. Yet they can't get off the dime, owing to the slough in which the negative-issue spinners (yes, the Democrats have negative agents too) have mired American politics.

That timid candidates of all stripes are now running from any mention of middle-class health-insurance reforms means that the situation for the poor and working poor must be even worse. It is. An estimated 16 percent of Americans lack health insurance--by far the worst percentage of any Western nation. (Germany, France, and Switzerland supply advanced care to all their citizens; yet they spend considerably less on a per-capita basis than the United States does because they use sophisticated systems that blend the best of private medicine with the efficiencies of national health care.)

Even if you don't care how much those without insurance suffer, consider this: Most of the "medically indigent" are not the hard-core poor (generally they receive free care) but the working poor, poised on the boundary line between being productive members of society and slipping back into welfare dependency.

If there's one thing that knocks a working-poor family out of the paycheck category and back onto the dole, it is medical expenses. Often the heads of working families, saddled by high medical bills, have no choice but to leave their jobs in order to qualify for free medical care. For any candidate who cares about making work more attractive than welfare, the 41 million Americans without health insurance ought to stand as one of the leading issues of the campaign.

But instead of addressing the needs of the uninsured, some of the presidential candidates have instead shown a perverse devotion to increasing their numbers. Congress is perilously close to turning Medicaid, the program that supplies free care for the poor, into a block grant under full control of the states. Two things will happen if Medicaid becomes a block grant. First, many states will reduce eligibility, causing even more Americans to lose health-care insurance. Second, care quality will decline; many state-run Medicaid programs are already disasters. Given that reality, it's remarkable that Congress now proposes to shift more medical responsibilities to the states. Remarkable--and yet par for the course in the current discombobulated health-care debate.

Gregg Easterbrook, a contributing editor of The Atlantic Monthly, is author of the recent A Moment on the Earth.