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More people lack health coverage. Nobody's sure what to do about it.

When reporters write about societal problems, they like to include whatever solutions the experts have suggested. The problem addressed here: According to 2002 figures, 34 percent of Arkansans had no health insurance, continuing a downward trend of several years. Nationally, nearly 1 in 3 people under 65 are now uninsured, according to a study by the Robert Wood Johnson Foundation. What's to be done? That's where this article departs from the norm. No one we talked to saw a light at the end of the tunnel. There's no consensus on universal health care. There's no consensus on how to limit medical expenses. There's no model on how to have both the most advanced medical care and to extend that care to everybody. Should health care be a right, as education is? If there is consensus, it is that something's got to give. Surprisingly, Arkansas may be the laboratory in which the cure is found. Tom Bruce, acting dean of the College of Public Health, calls health care in the United States a "failed system." Thanks to technology, pharmaceuticals, and doctor and hospital fees, not to mention over-utilization of expensive tests, "the cost is exorbitant," Bruce said. Government safety nets - Medicare and Medicaid - "are beginning to fray. Veterans' care is "virtually inaccessible because dollars are so limited," he said. "There's no control over the escalation, and everybody feels hopeless." That's a fairly bleak assessment, especially if you believe, as does Bruce, that a way to make health care available to all Americans has got to be found. He thinks that the College of Public Health can be the leader in finding the way. "We've got wealthy Northwest retirement [areas], the Delta with enormous poverty and social issues," diversity that reflects the nation, he said. Overlain on that is a web of state health centers that answer to UAMS, which offers a way to institute policy in a consistent way. "It's a perfect place to pilot some national approaches," Bruce said. Heading up the work will be Dr. Paul Halverson, formerly of the Centers for Disease Control in Atlanta, who on June 1 will assume the chair of the college's department of health policy and management. The problems of access are many. Dr. Bill Golden says some companies don't offer health insurance to their employees. Small businesses, thanks to health costs increasing some 14 percent a year, are increasingly unable to offer insurance plans, or if they do, they're asking employees to pick up a greater portion of the cost or are offering a fixed benefit rather than one based on need. Many employees find they can't afford the premiums the company plan requires. Nearly 71 percent of the uninsured are people with jobs - the working poor. Golden, an internist at UAMS who is doing research into the effectiveness of federal health programs with the Arkansas Foundation for Medical Care, sees a new area of concern: The insurance gap that's occurring between the age of retirement and Medicare eligibility. "Increasingly, people are being downsized," Golden said, laid off or urged to take early retirement." If you retire at 55, you have to wait until you're 65 to be eligible for Medicare, and that age is likely to be raised to 68, to offset losses from the robbing of Medicare to pay Paul. People who aren't eligible for public assistance can go to clinics at UAMS or elsewhere. "But they can't afford the medications they need," Golden said. "If you have sleep apnea [which can cause heart failure], I cannot get you care," because treatment requires a sleep study and a machine, a positive pressure mask. People on public assistance are also meeting roadblocks. Specialists "are avoiding taking care of these folks," Golden said. "If your practice was all Medicare, you'd go broke. You cannot cover your costs and make a living." The United States is now one of only two industrialized countries (along with South Africa) that do not offer national health insurance. "I don't think that, given the expectation of American patients, that there is enough money in the system to redistribute" and offer everyone high tech care. That such a system could be devised he called "a bit blue sky." The development of advanced medical strategies - such as the drug-eluting heart stent that keeps the artery clear, the gamma knife, new cancer drugs, HIV drugs, dual-chambered pacemakers - come at a substantial cost, which must be recouped somehow. In his research with AFMC, Golden has found that Arkansas spends $10 million of its Medicaid dollars to take care of 90 people, hemophiliacs who require an expensive, genetically engineered blood product. Eighty percent of the American health dollar is going to 20 percent of the population, Golden said. Should new priorities be considered? Limits on health care for the elderly and sick? The questions raise "Darwinian" issues: "If your patient's 75, what's the economic value to society to keep someone alive another year?" If you're the 75-year-old you might not want that question raised. Golden could offer no way out of the mess. But he added, "at some point we have to come to grips that we cannot provide everybody with everything." Bruce said policymakers are going to have to make fundamental changes, "get some control over the costs." In addition to raising the age of Medicare eligibility, the age at which Social Security kicks in will surely continue to go up, also. He predicts that the first rumblings for demand will come from the Northeast's rust belt, which has been hit hard by changes in the way industry does business. It's accepted in the United States that education is a right. (Arkansas faces huge problems with funding in this arena, also.) "We've got a system in place where nobody is denied an education," Bruce said. "We don't in health care." He predicts that a sacrifice will be required of everybody - doctors of their level of pay, patients of their services - if the country is to make health care, at its most basic, a right.
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