AT EVERY TURN the catastrophic health insurance bill has been improved in Congress. The compromise now building in the Senate is a further example; the legislation should be passed. But Congress should not do so blindly. A lot of gaps persist in the U.S. health-care system; this is one of many proposals to plug them. Each of these can easily be justified separately.
What neither branch of government seems to be set up to do is to examine them together and rank the needs and costs, establishing priorities. These proposals don't all mesh; if only for dollars, they compete. The risk is that, for lack of an overview, successive administrations and Congress are creating a crazy quilt of good intentions that we will all some day regret.
The catastrophic bill proposed to Congress by the White House contained a fairly narrow benefit, regressively financed. The House made it more generous, as expected, increasing the protection for costs already covered by Medicare and reaching out to cover some prescription drugs as well. But the more creative work was on the financing side. Contrary to its reputation, the House produced a disciplined bill. The program continued to carry its own financing mechanism -- and this was made progressive. The Social Security-Medicare financing system now accounts for about a third of federal revenues, and is mostly regressive. The catastrophic formula would be an interesting precedent in the opposite direction.
The main objection raised to the House bill had to do with the cost of the untried drug benefit. That is what the Senate bill would mostly fix. The benefit would be phased in; a series of caps and indexing formulas would be used to keep costs and revenues in tandem. It is tidy legislation. The administration, which opposed the House bill but hardly wanted to end up the skunk at its own garden party, has gratefully signed on.
What's wrong with that? Nothing except . . . The catastrophic bill is only for the elderly, a needy and compelling constituency. But others -- many poor people, poor children especially, families who have no health insurance through their work -- are also needy. It will never be a perfect world, but it's fair at least to ask: Who's neediest? Who should come first?
It's also right to tilt the catastrophic premium so that higher-income beneficiaries pay a greater share. But to help reduce the deficit, the Senate Finance Committee has meanwhile also voted to increase the basic Medicare tax in the upper-income brackets. This too seems right to us. But at what point do you tilt the burden too far, changing the nature of this social insurance program to such an extent that you threaten its political support? How wise is it to have so many different financing schemes for health programs, all for the same population? Those are the next questions Congress is going to have to decide.