WASHINGTON — More than halfway through a political season in which public concern about America’s porous, confusing and costly health insurance system has consistently emerged as one of the chief worries of a squeezed electorate, this is what we can expect when the new president takes office next year: not so much.

Neither presumptive Republican nominee John McCain nor Democrat Barack Obama, the likely nominee of his party, has pledged to cover all of the 47 million uninsured Americans who are falling through the cracks of a system that already is at a breaking point. Neither has proposed a health-insurance plan that would make health care more fair and equitable by putting everyone in a pool in which risks are shared among those who are healthy (but might one day get sick) and those who are not. This is how insurance — whether it be government insurance, such as Social Security, or private insurance, such as the policies we buy for automobiles — works. With everyone in the same system, everyone shares the burden of paying as well as the benefit of coverage when it is needed.

Because of the crucial failure of both candidates to acknowledge this elemental truth, the nation is likely to stay on the crooked path down which it has staggered since the employer-based system of care began to unravel at least two decades ago.

But don’t both McCain and Obama say they want to fix the system, covering more people and lowering costs for everyone? Sure. But talk is cheap — much cheaper, apparently, than the political costs of more comprehensive action that would either anger ideological supporters on the right (if you’re McCain) or raise that old chestnut about “socialized medicine” (if you’re Obama).

McCain’s plan, because it seeks to placate a right wing for which any hint of government intervention is apostasy, would effectively dismantle the current employer-based system by eliminating the tax deduction that businesses now get when they pay the health premiums for their employees. Most experts say this would quicken the pace at which employers are dropping coverage.

McCain would provide tax credits for individuals to purchase insurance, but he relies on the unproved theory that if full costs and responsibility for insurance were shifted back to individuals and families, prices would drop. “This is a ‘back to the future’ plan, returning us all to the period before the creation of employer-based group insurance in the 1930s, when individuals and families were ‘on their own’ to find ways of paying for their health care,” concludes an issue brief by Rekindling Reform, a New York-based group of social welfare agencies, unions and religious, academic and public health organizations.

Obama’s plan is a lost opportunity.

Yes, it would curtail some of the more egregious insurance industry practices and seeks some cost containment. But it still fails to recognize that without some kind of mandate to bring everyone into the system — either an individual mandate, like his Democratic rivals Hillary Clinton and John Edwards proposed, or a nationwide requirement, such as a Medicare-for-all type of system — insurance companies still would be able to cherry-pick among those they want to insure and those they don’t.

“Where his [Obama’s] falls down is that it’s not universal,” says Aaron E. Carroll, director of the Center for Health Policy and Professionalism Research at Indiana University School of Medicine. “He’s still trying to build this on a patchwork system.”

Though Obama proposes a mandate that all children be covered, he has no clear way to enforce this beyond what many states already do for the current State Children’s Health Insurance Program (SCHIP). That is, he would do outreach at schools, day-care centers and hospitals to try to get parents to sign their kids up. “Mandates like this are incredibly inefficient,” Carroll says, and would be unlikely to enroll many more children than the state and federal governments already have.

The good news, I suppose, is that if McCain wins the White House, Democrats probably will continue to control Capitol Hill. They would be unlikely to enact anything so radical as the McCain proposal. The bad news is that if Obama wins, his party will have squandered the best opportunity in more than a decade — since the Bill Clinton era — to take a bold leap toward the universal coverage Democrats have promised since the presidency of Harry Truman.

Marie Cocco’s e-mail address is mariecocco(at)washpost.com.

© 2008, Washington Post Writers Group

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