Molly Ivins October 24

How about a peppy column on health care? You say there's no pep left in that pup: such a muddle we all hate to think about it? I reckon different. Robert H. Frank, a professor at Cornell University and big-time expert in all this, says, "In short, our health insurance system is in a death spiral." That may not be peppy, but at least it's arresting.

Frank's thinking is that as more people cancel their health insurance — because of day-to-day financial distress — going without health insurance becomes more socially acceptable.

"Making matters worse is the changing composition of the pool of the insured. As more healthy families forego coverage, those left tend to be sicker and more costly to treat, forcing up premiums," he said.

Likewise, says Frank, there's a similar impetus on the employer's side.

"Not long ago, many workers never would have considered a job that didn't cover health insurance. As more employers, particularly small businesses, offer jobs with no coverage, it becomes more difficult for workers to avoid them. In turn, these employers have lower operating costs, allowing them a competitive edge and putting further pressure on businesses that continue to offer such benefits."

Frank offers an interesting variant on the classic simple solution to all this. Those of us who have agitated for a single-payer system, modeled on Canada's excellent program, might want to consider Frank's alternative, not because it is better but because it is more politically doable. Frank proposes a flat-out subsidy by the government for health-care insurance, up to $3,000 a year per family.

For one thing, this would not drive private health insurers out of business — and as you know, their opposition and generous campaign contributions have tied our political system into knots: Harry and Louise were a dubious gift from the insurance industry. Government bureaucrats would simply process health insurance claims and send out checks; we buy the insurance and choose the doctors, and they choose the treatments.

Frank claims this will work out to be cheaper than the present system because it would deliver more cost-effective care to those currently uninsured. The uninsured tend to let minor illnesses grow into major illnesses before seeking treatment and then wind up in emergency rooms.

Of the presidential candidates, only Bill Bradley has made a thorough, thoughtful health-care proposal, and he concedes it would still leave about 5 percent uncovered by insurance. Some of his political opponents claim his plan would be vastly more expensive than estimated — but then, they always claim that about health-care plans. Hard to think of any system vastly more expensive than the one we have.

Also sneaking up on us is a crisis in care for the chronically ill.

This is one of those stories that seep and creep: No one has hired a public-relations firm to blare an emergency at a press conference, so it gets little coverage.

Heart and lung disease, for example, do not fit into the system of care designed for cancer patients. Cancer patients need relatively little help until the last six months, when they tend to go downhill fast. The superb hospice system was specifically designed for them. But frail, older patients with chronic illnesses need five to 10 or more years of care in a sort of roller-coaster pattern over the years. A recent study in the New England Journal of Medicine found 23 percent of such patients in serious need of care, and much of what is provided comes from family members, particularly women, at an enormous cost in stress.

Mona Harrington's new book, "Care and Equality" points out that the whole system of care is broken in an even larger sense. Who is now caring for America's children, the sick, the disabled? Harrington reports that essentially nobody is. The traditional system depended on the unpaid labor of women in the home. And women are no longer home.

Women, as most of us are well aware, are caught in two double-binds. One splits us between the needs of children and the needs of aging parents. The other is a no-win game of societal expectations.

Middle-class working women are constantly guilt-tripped about not staying home to care for their children, while poor mothers are shoved into the workforce by society that tells them they are a disgrace if they stay home on welfare.

Harrington writes of "the remaining power of the idea that women are most admirable, most virtuous, most worthy of praise when they are fulfilling the supportive role of wife or mother. And the same idea defines women as least praiseworthy when they seek to enter to the world of power that has always been the often unlovely province of men."

Harrington calls for a new kind of pro-family politics, an ethics of care in a public-private partnership.

"To achieve equal economic opportunity for women within a system that takes care seriously and values families, we must extend the reach of public responsibility," Harrington writes. "We have to go beyond righting wrongs to the deliberate political building of a family care system that includes the value of equality. ... I believe it should be in a public-private collaboration, but one that imposes definite responsibilities for care on the private sector. The reigning idea that the sole corporate responsibility is to create value for shareholders must be replaced by one that expands corporate obligation to include social health — and that means an obligation to support families and care."

Her argument is that a huge proportion of the great wealth created by American corporations is going not only to shareholders, but to corporate managers — in salaries, stock options and perks — while the share that goes to workers declines or stagnates, even in boom times. Thus, families do not have the resources to care well for their children.

Molly Ivins is a columnist for the Fort Worth Star-Telegram. To find out more about Molly Ivins and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate web page at www.creators.com.

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