IF YOU are the leader of an effort to push the health care system into affordable shape, you may want to be careful about how you present your thoughts. The objective, surely, would be to get everyone on board for changes that everybody won't like - though many would support if they thought the program could be saved.
In pursuit of this all-aboard objective last week, Gov. Robert L. Ehrlich Jr. blitzed into the arena with rhetorical impulses unchecked.
Speaking of Maryland's health programs, Mr. Ehrlich said, "If you can afford a Cadillac, that's terrific. But for some folks, you need to start out with the Pinto."
After reading this observation in their morning newspaper, fearful health advocates made telephones ring off the proverbial hook.
Pintos blew up, said one caller.
I know someone who bought a Pinto and a door fell off on the way home from the dealership, said another.
We don't want a Pinto health care system for our kids, they said.
Certainly not, but guess what? We've got one now. Our system's blown up, the doors have fallen off and the tank's empty.
The evidence is everywhere and must be hitting every family in one way or another. Some 600,000 Marylanders have no health insurance. Hospitals and doctors are finding it harder and harder to stay in practice for numerous reasons: low reimbursement rates, uncompensated care, rising malpractice insurance premiums. The Medicaid program threatens to bankrupt Maryland and other states. Seniors can't afford the drugs they need.
So, the upside of Pintogate is visibility. Solving the health care riddle will be staggeringly complicated, involving many numbers and the interplay of co-pays, poverty indices, federal matches, small market plans and other terms from the arcane land of health care. The exploding, door-free Pinto, at least, we understand as metaphor.
It will be the job of the health care advocates and political leaders to lead us through this maze of numbers and sound bites to rational answers. Ten years ago, long before Monica, Bill and Hillary Clinton lost an opportunity to address the health care dilemma. Opponents said there was no dilemma, railed against bureaucracy and stood down. Failure meant something like leaving the arena.
Now, because Washington can't deal with it, or won't, the job falls to governors such as Mr. Ehrlich and his health secretary, Nelson J. Sabatini. They're going to have plenty of help from the anti-Pinto crowd.
Vincent DeMarco and the Maryland Citizens' Health Initiative, pioneers in this effort, urge their plan. They would use a higher cigarette tax, a tax on employers and various other revenue sources to pay for a plan that would bring every Marylander into a reasonable system. Their plan has this virtue: Whether the numbers compute, at least there are numbers to evaluate - not always the case with other proposals. Mr. Sabatini would pay for his plan with tax credits given to businesses by the state in return for providing health insurance. Mr. DeMarco and his group say the Sabatini plan - authored by former House Speaker Casper R. Taylor Jr. and endorsed by various businesses groups - won't raise enough money.
What's good about all this debate is - the debate. Mr. Sabatini said recently that he and Mr. Ehrlich are in conceptual agreement that universal health insurance could happen in Maryland. That was splendid, a breakthrough.
It may well be true that Maryland has given its poor citizens a better health insurance program than it can afford - that's what lay at the heart of the Pinto quote. Many would dispute that contention because Maryland is an extremely wealthy state and because what seems generous at one point in the health care continuum saves money at another end: Preventive care in a doctor's office is less expensive than emergency room treatment.
Nevertheless, in a time of economic difficulty for the state - made worse by a health system that increasingly seems insupportable for families, individuals and businesses - the program may have to be made smaller. Eligibility might have to be circumscribed. The package of benefits might have to be smaller.
Maybe it'll be a Cadillac plan. Maybe it's a Pinto or a Yugo.
This much we know: What we have now is unsafe at any speed.
C. Fraser Smith is an editorial writer for The Sun. His column appears Sundays.