Caroline Poplin

is a physician, lawyer and visiting scholar at Georgetown University Law Center

The issue is health care. Have you noticed that presidential candidates assume that universal health insurance means universal health care? They use the terms interchangeably. They assume that once the law enables or requires everyone to buy health insurance, everyone will have adequate health care.

But anyone who has been seriously ill or cared for a sick relative knows that while health insurance may be the solution, too often it is part of the problem.

In fact, health insurance and health care are two different products for two different markets. Health insurance is for healthy people. Health care is for the sick. What we need to lead full, productive lives is good health care. Insurance may be one way to get there. But keep your eye on the ball.

Well, you say, automobile insurance works well in this country. We require all drivers to have insurance to cover the expenses of innocent victims.

But think about automobile insurance. Most drivers don't get into accidents. Many people have never been in a serious accident. In fact, insurers can calculate the rate of loss for a large group of people and set premiums accordingly. Statistically, teenagers get into more accidents; their premiums are correspondingly higher. There are a few drivers who are much worse than average whom no one will insure, so they go into a high-risk pool covered by state mandates.

Two other features of automobile insurance are important. First, the insurer's liability is limited: for the victim's car, to the price of a new car, and for the victim, to a fixed amount of money, not whatever it takes to restore the victim to health.

Second, no one's auto insurance covers routine maintenance. That is a predictable expense, part of the cost of owning a car.

There was a time when health was like driving. Illness or injury was sudden, unpredictable and brief. You either recovered, or you died. Medical care was not expensive, and (surgery apart) not terribly effective. Insurance did not cover doctor visits for minor problems or for physicals, any more than car insurance covered routine repairs.

Since then, medicine has been transformed. Many people no longer die from heart attacks, pneumonia, cancer, even HIV/AIDS; they may live many years if they are treated promptly, aggressively and often long-term.

These patients are no longer average drivers. They have "pre-existing conditions" and are thus at high risk for predictable, serious, expensive, often chronic complications. A diabetic patient is at high risk for heart attacks and kidney failure. Many cancer patients are at high risk for pneumonia. Even someone with uncomplicated high blood pressure is at increased risk for heart attack and stroke.

Commercial insurance was never designed for situations like this. No one sells flood insurance for a house that regularly floods.

So insurers routinely exclude pre-existing conditions from coverage. Most commercial health insurance, like car insurance, is intended for one-time, unpredictable expenses.

But people with pre-existing conditions, the chronically ill, are exactly the people who need health care the most. They can get it now only if they qualify for public programs like Medicare, or they work for large employers who can spread their expenses over a large, mostly healthy, workforce. The chronically ill are disproportionately uninsured.

Yet the number of people with chronic illnesses is large and growing. For example, it is estimated that 30 percent of Americans have high blood pressure.

There are some goods the private market just cannot provide efficiently, that we need to purchase collectively: defense, roads, sanitation. The rest of the developed world believes that health care is another.

Given America's love affair with markets, I propose we split the difference. Let those who can obtain good insurance buy it. Let those who can't get decent insurance at a reasonable price buy into Medicare.

But remember, wherever the debate goes, keep your eyes on the prize: the real goal is not health insurance, but universal health care.

E-mail Caroline Poplin at cmpoplin@aol.com

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