Take California, the largest state in the nation. Add New York City. Now throw in Detroit. This closely approximates the number of people in the United States who have no health insurance - 43.6 million of them, or 15 percent of the population.
As the number of uninsured expands, and the cost of health insurance dramatically rises (last year, premiums for employer-based plans went up nearly 13 percent), the question of how to cover the uncovered has again turned into a major presidential campaign issue. With the Clinton administration's failed attempt at wholesale healthcare reform serving as a lesson, we hope this time Washington knows better what will work and what won't.
It may be tempting to think that universal health insurance - that is, providing coverage to all Americans - should be the goal. Just this month, the Institute of Medicine, which advises the federal government on health policy, succumbed to that temptation when it recommended that Washington devise a plan to cover all Americans.
Their reasoning is understandable on humanitarian grounds. The Institute reports that "lack of health insurance causes roughly 18,000 unnecessary deaths every year." Health-policy experts also argue that insuring everyone would improve the medical system's efficiency, because the number of patients would be known, and many more health problems would be caught early.
But any sort of universal coverage would probably mean some kind of congressional mandate, requiring either employers to guarantee coverage, individuals to buy insurance, or the federal government to provide coverage - or a mix of some or all. Mandates, however, don't go down well in America's free-choice society. And as the Clinton effort showed, neither does it work to try and overhaul an industry the size of the French economy.
That's why this year's presidential contenders, from the Democrats to George W. Bush, are right to stay away from a complete healthcare makeover, and instead work to fill gaps in the nation's largely private health insurance system.
Because both Republicans and Democrats want to take credit for enlarging the health-insurance tent, it's likely neither will bend enough before the fall election to allow any measure to pass. That doesn't mean however, that consensus can't start building for the nonelection year of 2005. Why not combine the core suggestions of the Democratic candidates with those of President Bush? The ideas are not all mutually exclusive, and the pool of uninsured is large and varied enough to accommodate elements from both parties.
One can imagine, for instance, broadening the State Children's Health Insurance Program to reach more poor people, and providing all Americans access to a version of a group plan that federal employees now receive, as most of the Democratic candidates suggest. President Bush's idea of using tax credits to reduce premium costs for individuals also makes sense. In fact, several Democrats also propose tax credits.
Together, these ideas could widen the safety net for those who can't afford insurance, yet offer more choice for those who could.
The real test of political will is less likely to be which tools to apply to this problem, than how big a solution to build. Can a large chunk of the uninsured be helped, as candidates Wesley Clark, Howard Dean, John Edwards, John Kerry, and Joseph Lieberman propose? They say their plans would cover anywhere from 21 million to 32 million people.
Or does the country take a more modest approach under the Bush plan, covering as many as 7 million of the uninsured?
This answer rests on cost, which is why every leading Democratic candidate says it's necessary to rescind some of the Bush tax cuts to pay for their plans. Their estimated price tags range from nearly $700 billion over 10 years to a more modest $275 billion over five years. Still, these greatly overshadow the Bush-projected cost of $89 billion over a decade.
Americans deserve to have this issue addressed. In November, voters will have a chance to send Washington a signal on how big or how small a fix they want for this particular issue - and at what price in taxes or in a larger federal deficit.