COMMENTARY:

THIS YEAR Congress will consider a program of catastrophic health insurance for aged and disabled Medicare recipients. Such a program would be of immense help to the millions of Americans who live in fear of bankruptcy or--even worse--of not receiving medical care they may desperately need should catastrophe hit. But Congress should not wallow in self-congratulation if it passes this extension of Medicare. Although important in itself, it would not address other even larger health care financing issues.

The fact is that 37 million of us under the age of 65--or one out of six Americans--have no health insurance at all. And that number is growing--it has increased by 10 million, or 37 percent, since 1979. And millions more may subscribe to programs passing themselves off as "insurance" but that are hardly adequate. They can pay as little as $50 for every day the subscriber is in a hospital. The average cost for a day in the hospital in the U.S., meanwhile, is $600.

The fact also is that U.S. health care expenditures total some $450 billion per annum. And that number is also rising. Health care expenditures add up to almost 11 percent of our Gross National Product. Thus the average American works six and a half weeks per year to pay for health care. (Canadians work only about four and a half weeks to pay for theirs.)

SO WE have here in America a curious situation: we spend more on health care than other industrial nations, yet a larger percentage of our citizenry is without financial protection. At the same time we are told there is a surplus of physicians and hospital beds, millions of Americans lack assess to health care. Just as we have people going hungry in a land that could grow more food, so we have people who get sick unable to enter a system that could help them. We are far, and getting further, from equity of access.

How did we get here? Why are we and South Africa the only industrial nations without some form of universal health insurance? What would a detailed description of a program to rectify the situation and to translate the concept of a right to health care (one of the hallmarks of a civilized society) into operational terms look like? Full answers to these questions would take us beyond the space available. But this we know:

1. Many Americans can't pay for the care they need and go without it.

2. Still others do get "free" care, often under demeaning conditions and paid for by those who have insurance through "cost shifting."

3. This neglect and cut-backs in various assistance programs have contributed to an increase in our infant mortality rate--a traditional, albeit incomplete, health indicator.

4. The shift from unionized manufacturing jobs to non-union service employment will continue to swell the ranks of those without health insurance. Absence of insurance is not simply due to unemployment. Over half of the uninsured adults are employed.

5. We are in the midst of profound changes both in health insurance and in health-care delivery systems. Many of these changes increase health sector competition. Competition has many positive aspects; for example, it increases consumer choice and weeds out the less efficient. It is no wonder that Americans prize competition. But these benefits also involve costs: for example, potential declines in quality and segmentation of the insurance market and delivery system as subscribers try to disassociate themselves from those more likely to be sick.

UNLESS WE act, our problems are likely to grow worse in the years ahead. America needs a universal health insurance system that removes economic barriers to care. But such a system must assure that we spend as a nation an "appropriate" amount, relative to other needs and wants, on health care. A national health insurance system--with a much larger administrative role for the individual states than earlier versions of NHI called for, a setup somewhat akin to the Canadian system--with expenditure limits would meet our needs.

Of course, such a system would be cumbersome. But so are today's arrangements, as anyone who has filed a reimbursement claim can attest. The point is that it would be more equitable and responsive to our collective judgement on the appropriate allocation of resources to health care.

We should not turn away from the task of seeking equity simply because the goals we seek require complex mechanisms. What's at stake is our image of ourselves. What should spur us on is the knowledge that 37 million of our neighbors don't have financial protection from the costs of illness. What should help mobilize us is the fact that if we fail to act, tomorrow or the next day or week or year you or I may be among those who help swell that number.