What is it that we don’t understand? Study after study indicates that it is cheaper to cover everyone than it is to cover some and provide charity and uncompensated care to others. Timely care is far cheaper and more efficient, let alone more compassionate, than delayed care in an emergency room.

The big news this year, of course, is that Massachusetts just passed legislation requiring everyone to take out health insurance the same way they take out car insurance. It is advertised as “near universal health care.” Contrary to the headlines, the Massachusetts plan does not actually provide insurance coverage. Rather it offers economic incentives and disincentives for the purchase of commercial insurance. Sliding-scale subsidies are available for the purchase of private insurance by uninsured families with incomes up to 300 percent of the federal poverty level ($49,800 for a family of three). Those who remain uninsured by July 1, 2007, will forfeit their individual state tax exemption, and by 2008 they will have to pay a penalty equal to half the cost of the insurance plan they could have purchased — but only if commercial insurers are deemed to be offering insurance at an undefined “affordable” price.

Employers of 10 or more people who do not provide insurance are penalized only $295 per employee, leading many to wonder if companies will actually drop employee coverage in favor of the penalty.

Massachusetts’ seeming success is due in great part to political correctness, to genuflecting to the values of individual responsibility and market solutions. Forget the fact that obtaining health care is not like buying toasters and that commercial (as opposed to public) coverage adds an extra 15 percent or so to the cost of health care. Yet this is a major political step, taken with bipartisan support. That should be celebrated. The fear is that a false promise can taint enthusiasm for efforts elsewhere.

At least the folks in Massachusetts have realized that insurance will never be affordable until everyone is in the pool. But the problem isn’t just insurance coverage. In Massachusetts, as elsewhere, they have yet to fully appreciate other interrelated truths. Insurance will never be affordable until:

• The spiral of rising prices can be tamed.
• We do something about reducing the need for so much health care.

The Massachusetts “solution” has its roots in the notion that the cost of care for the uninsured is presently shifted to others in higher taxes and insurance premiums. That is true. But we must do more than simply shift the cost from one group to another. We must achieve more than the “fixes” of disease management, information technology, and quality control, as important as those efforts are.

We must look at changes that affect how many doctors are available and how much time they spend with patients, whether people smoke when pregnant or exercise daily, what we eat and how much we exercise, when clinics are open, whether we allow terminal patients to die or engage in heroics, and whether our communities invest in long-term care facilities and provide support for noninstitutional care. Some solutions will take a generation. (Remember when people smoked at work?)

Finally, we must answer some hard policy questions. What health-care needs can we realistically expect all citizens to provide for themselves? What level of health care does society owe its neediest citizens? When should health-care cost be shared on the basis of wealth (the rich paying more than the poor)? When should it be shared according to need (everyone contributing the same)?

During the past session, the Legislature stepped back from actually instituting a march toward universal health care. In its place, it established an Interagency Health Council empowered to “establish the standards and criteria for evaluating the unmet health-care needs within this state, to evaluate methods to meet those needs and to set forth recommendations related to services provided and services needed, access issues, and related financing proposals.”

The hope is that such a group can look beyond tweaking current insurance programs and optimizing current practices. Regrettably, the council has been given neither additional staff nor additional funding to pursue their noble goals. It must work from the assumption that all unmet health-care needs can be met within current funding. Any new proposal must be at least cost-neutral. Which is not to demean their efforts, simply to observe that they have been charged with a short-term administrative task rather than long-term strategic planning.

As the council gears up, the state can continue to support the creative initiatives of the Pharmaceutical Cost Containment Council, move ahead with the pilot pre-paid clinic program approved by the Legislature, and finally establish the much-talked-about central pharmacy to streamline the delivery of free manufacturer-donated drugs to low-income patients. We can look to the ongoing meetings of the voluntary Vision Shared task force on long-term care as a model for proactive long-term planning, and trust that the recently mandated comprehensive study of the state’s behavioral health system is as forward-looking.

Cover the Uninsured Week is a time to tell Congress that health coverage for Americans must be their top priority. And to hope that maybe one day we cannot only cover the uninsured, but also provide affordable, quality health care to all.

Kurland is health action coordinator of Covenant House and creator of the Web site www.criticalreading.com. He served on a state medical planning task force.