Saving the safety net. (Guest Editorial).

Politicians have long debated the need to fix our health insurance system. But if we are to meaningfully address the present crisis in health care costs, access, and quality, we must be willing to directly challenge the very underpinnings of the system we know today--particularly Medicaid and Medicare.

First, there is currently no explicit policy to finance health care for the poor. Instead, we have a system where eligibility is based on "category;" not necessarily on financial need. In Medicaid, for example, single parents and couples with children are eligible, but single poor people or couples without children are not.

Medicare, on the other hand, is available to everyone in the category "over 65," regardless of their income. When Medicare began 40 years ago, most of the beneficiaries were poor, with few outside resources. But the elderly today represent one of the richest sectors of society;

In the last four decades, the health care debate has been both framed and limited by this concept of "categorical eligibility" Strong lobbies have sprung up to defend those within existing categories. As part of our effort to reform the current system, we must take another look at Medicare and Medicaid. There has been no challenge to the premises that these programs were built on, and that has to change.

Although the U.S. health care system does not explicitly cover all poor people, it does contain many "implicit subsidies" for other groups. In addition to Medicare, which subsidizes health care for Americans over 65 years of age, employers can deduct health care costs from their company's taxable income, and employer contributions to health care premiums are not counted as taxable income for employees.

Most of our problems in the health care system derive from the fact that these policies are implicit policies. If they were explicit--if we had to write them down--they would be difficult to defend. For example, who could defend a policy that openly established categories to ...