Although we have not seen a published correlation, it is reasonable to assume that the employed with health insurance vote more frequently than the chronically unemployed with no insurance, or just the chronically uninsured (who says there is no bias in the press?). And politicians tend to cater to those who vote, especially those with money.

So far, two Democratic contenders have released their blueprints for the future of health care in America, and both have focused on the uninsured. As expected, Representative Richard Gephardt’s plan is the most expensive at a cost of almost $250 billion annually when fully implemented. He wants all employers to offer insurance to all employees working more than 20 hours per week, with the employers paying at least 60% of the premium. This is estimated to cost businesses $36 billion annually after a 60% "tax credit," but since you have to be profitable to pay taxes, it is questionable how many of the companies that would now be paying health insurance premiums would be in a financial position to receive a credit, unless it is a federal cash rebate.

Mr. Gephardt’s plan is supposed to result in just over 30 million newly insured people, or almost 75% of the commonly used 41 million uninsured in the country (more on this number later). Here is where we enter the terrain of high math. Dividing the assumed annual cost by 30 million people produces a per capita cost of approximately $8,300 per year. That, however, could pay the full insurance premium for a family of four in some parts of the country, or two single adults anywhere, and we are not talking about a restrictive HMO policy. Since many of the uninsured are young adults and children, the cost of which is relatively low to insure, there appears to be a significant gap in what we get for each dollar of cost. Health insurers would stand in line to receive $250 billion per year to insure 30 million people, and would do it to insure the full 41 million. Obviously, this trial balloon is going to burst at first blush and will receive about the same traction as Mr. Gephardt’s previous campaigns for the White House.

What he fails to realize is that many of the working uninsured cannot afford to pay 40% of the premium any-way, preferring to use their low wages on housing, food and clothing (seems reasonable). This is a problem with former governor Howard Dean’s plan as well. It also expects to cover more than 30 million of the currently uninsured, but at a total annual cost of $88 billion. While the cost/benefit seems reasonable, especially compared to the Gephardt plan, some of the details are dubious, such as extending tax credits to the uninsured to help them pay for health insurance, when many of them pay little in taxes anyway.

The new net cost to businesses of the Dean plan is just $2.9 billion, and if that’s believable, there will be little resistance from the captains of industry. In addition, Dean offers the reasonable idea to have employers who offer insurance to continue to pay their share of the premium for two months after an employee leaves, as long as insurance coverage has not already been provided by a new employer. While some of the actual details of the Dean plan are not yet well-defined, it does appear to come up with ideas that will help alleviate the high cost of insurance for the "working poor," and builds from various health insurance plans that appear to work.

The concept of the "uninsured" itself is a cloudy one, at best. A recent report by the Congressional Budget Office (CBO) stated that at some point during each year nearly 60 million people lack health insurance. Apparently, most estimates do not distinguish between those people who lack insurance for a few months and those who are uninsured for more than a year, i.e., the chronically uninsured. The CBO estimates that the commonly used 41 million uninsured figure overstates the real problem, which is the 21 million to 31 million people who are chronically uninsured—9% to 13% of the nonelderly population.

Unfortunately, some politicians like to use scare tactics that just don’t hold up under simple scrutiny. For example, Democratic Senator Jeff Bingman of New Mexico was recently quoted in The New York Times as saying "On any given day, more than 40 million Americans live with the prospect of facing financial ruin in order to pay for their health care, or going without care altogether." First of all, unless they are currently sick, most of them are not thinking about health care, and if they are not sick, they aren’t going to face financial ruin.

Second, emergency care will always be given at a hospital, admittedly an expensive venue for treatment, but one nonetheless available to all, and everyone knows it. What uninsured people will forego are check-ups and routine tests that may prevent much more expensive treatment at a later date. But many of the uninsured are young and healthy, and any way you slice it, it is not a $250 billion per year problem, or cost, and Mr. Gephardt will lose this one (again).

What both Dr. Dean and Mr. Gephardt fail to do is reconcile their plans for the uninsured, and their respective costs, with the rest of the health care system. For example, what are the projected savings to the health care system (reduced emergency room treatments) if the number of uninsured declines? What is the cost savings to the health care economy of early detection of serious medical conditions for these 41 million uninsured? How much would the cost of care, and thus health insurance, decline if there were serious tort reform? And finally, will any politician step up to the plate and propose something that makes individuals take some responsibility for their own health? An example would be making all smokers pay a higher premium (since they contribute to a disproportionate share of the costs), which would make the cost of health insurance more reasonable for everyone else.

Who benefits from more people covered by health insurance? In theory, the health insurers, and Mr. Gephardt’s plan could be very lucrative for them, although that is certainly not his intent. But it all comes down to what the actual premium will be, something that remains cloudy under any plan so far. Several years ago, Medicare HMOs were supposed to be one way to privatize the popular health plan for the elderly. The problem was that most insurers began to lose money and one by one dropped out of the program. And other than a few specialist companies, insurers haven’t found Medicaid managed care to be overly profitable.

Although something closer to the Dean plan has a better chance of succeeding, dealing with the uninsured is not going to be the primary health care issue before or after the 2004 election. Unless, of course, we continue to have double-digit increases in health insurance premiums, and then the chronically uninsured will rise dramatically as the premiums become too high for even middle-income households. At that point, business leaders will finally exert pressure for change. Managed care companies are currently producing tremendous profits (see below), but the pendulum will swing back in the next few years, regardless of who wins the election.

A prescription drug benefit for Medicare recipients will still be the number one topic in Congress, followed, presumably, by tort reform. With a physician in charge of the Senate for the first time, there may finally be some movement on the latter issue (naïve as that sounds). It is one thing to have health insurance, but quite another if you have to drive 45 miles to find an obstetrician who will deliver your baby.