HEALTH care has been one of the many issues where the United States has stood apart, opting for rugged individualism over collectivism. Some form of what many Americans call ``socialized medicine,'' such as Britain's National Health Service, is taken for granted in most of the West. These systems are not without problems: Britain has over half a million people on waiting lists for elective surgery.
But America's system is an expensive patchwork - employer-paid health insurance for millions, medicaid for those on welfare, and medicare for the elderly. For the working poor, there is nothing. For many others, there is less than there could be. A short hospital stay can put a working-poor family onto the streets.
Now Michael Dukakis, the Democratic candidate for president, has committed himself to a proposal, modeled on a new Massachusetts program, requiring virtually all employers to provide health insurance for their employees. He also proposes to seek ways of insuring for those neither employed nor under the welfare/medicaid umbrella.
In a campaign often derided as ``content free,'' this proposal is notable for what it's not: It's not a plan for a national health service. It would build on the existing reliance on employer-paid insurance, rather than instituting a new bureaucracy. It would not be a direct draw on the US Treasury or an excuse to raise taxes.
But mandatory health insurance would have its costs. The business community would perceive it, correctly, as a hidden payroll tax - specifically, on small business, since most larger employers already provide insurance. It would also burden employers of low-wage earners disproportionately and probably keep some employers from expanding their work force. Mr. Dukakis favors an exemption for the smallest employers, but hasn't spelled out details.
Continuing with the current patchwork would have its costs, too. In 1986 the US spent 11.1 percent of the gross national product on health care, nearly twice Britain's proportion. But on some measures of public health, such as infant mortality, the US ranks with parts of the third world. Ways to reduce infant mortality are often very simple - counseling women to avoid alcohol, tobacco, and drugs during pregnancy, for instance.
By expanding the access to health care in such cases, much could be done for relatively little. Big businesses already absorb indirectly some of the costs of health care for the uninsured.
If the working poor and others not covered by medicaid could receive the benefits of something like the community health services that have been well received in Britain (most of the problems have been in Britain's hospital-based services), much expense and emergency-room drama could be avoided.
The Dukakis proposal may not be what the US should adopt. Massachusetts, with its highly paid work force, may not be the best model for the rest of the country. And cost containment will surely have to be an element of whatever happens with American health care. But the governor deserves credit for raising the issue.