WASHINGTON -- Answer me this: If your purpose is to reduce the ranks of the 45 million people with no health insurance, what sense does it make to throw scarce federal dollars at people who already have health insurance?
Or this: What sense does it make to throw more of those scarce dollars, in the form of tax deductions for premiums, at people who not only already have health insurance but are also filthy rich?
Welcome to BradleyCare. When the former New Jersey senator made his proposal, he got praise (including from me) for breaking new ground, putting the principle of universal coverage back on the table credibly, and breathing fresh policy air into a stale, partisan shouting match.
As with any big idea, there were holes involving cost, coverage, Medicare, and Medicaid. But expectation was that probing and discussion would produce more answers and refinements that would further improve Bill Bradley's signature new idea.
Hasn't happened. As a result, what Bradley has dismissed as ''timid'' - Vice President Al Gore's ideas - now loom as sensible, workable, and more progressive. By building on what already exists, Gore has a way over the next decade to increase insurance coverage to almost the level Bradley's ideas would, but at a cost that doesn't gobble the lion's share of any budget surplus, leaves room for investment in Medicare, and also leaves room for investment in other national priorities.
This is not a left-right, liberal-moderate ideological squabble. As with so many other big issues in the '90s, it is a case where the most progressive ideas turn out to be the most fiscally responsible.
On health care, the Gore-Bradley debate can be boiled down without too much oversimplification to three issues - cost, coverage, and the bedrock federal entitlements, Medicare and Medicaid.
Bradley's proposal doesn't cost more than Gore's because it is more nearly universal. It costs more, at least three times more, because it offers subsidies for everyone regardless of need, and regardless of whether they already have insurance. More dramatically, it costs a lot more because of a prescription drug benefit that while stingy on the front end is open-ended on the back end.
The Bradley proposal's fiscally dangerous assumption is that every Medicare beneficiary over age 80 would enroll in an HMO to get the drug benefit. But there are currently only four such outfits in existence. What we do have reason to expect, from work by the Congressional Budget Office, is that at least 80 percent of Medicare beneficiaries would sign up for the drug benefit. The difference between CBO analysis and Bradley hope is huge. Dr. Kenneth Thorpe of Emory University last week pegged the 10-year cost at nearly $400 billion.
In addition, Bradley's proposal would cost more because it makes insurance premiums tax deductible for everyone and gives subsidies on a sliding scale to people who have insurance, and not merely the uninsured. In all, Thorpe pegs the 10-year cost of BradleyCare at slightly more than $1 trillion, which consumes the entire projected surplus.
The Bradley campaign, rather than refute Thorpe, attacks him as damaged ''Clinton-Gore'' goods. But his first-term job was working on his field of expertise, cost-estimating. His initial projections about the Bradley and Gore proposals came after a request from The Washington Post, and his revised work last week came after Bradley's people sought to persuade him otherwise. He could not responsibly agree to their assumptions.
Bradley's costs are supposed to be for a worthy purpose, attaining insurance coverage for nearly all the uninsured - which would produce savings in acute care expenses as well as better health.
However, the question has arisen whether, for example, the existence of the subsidies may cause many employers to dump coverage, or what would be the impact of ending Medicaid as we know it, as Bradley has proposed, on AIDS patients or low-income nursing home patients who couldn't buy insurance with the vouchers they would get in ''exchange.'' What more likely would be in store would be substitution of public dollars for private ones. Thorpe figures Bradley's proposal would add 15 million people to the insured population, compared to 12 million in Gore's plan, which is targeted on kids and adults with no insurance. Bradley would end up insuring 89 percent of the population, compared to 88 percent with Gore's plan, but would spend $700 billion more. Gimme a break.
Ending Medicaid as we know it is dangerous enough if you keep in mind adults for whom it is a vital safety net. But BradleyCare virtually demands ignoring Medicare.
That's not responsible. Medicare will need both reform and new money over the next decade to be ready for the baby boom generation's retirement. Simply to assume, as Bradley does, that because the program appears solvent under current economic conditions until the year 2015, it doesn't need attention upfront, is quixotic. Gore, like President Clinton, more wisely wants to invest 15 percent of any budget surplus in Medicare's future.
This could have been a better debate. But by going for pie in the sky, Bradley has crashed.
Thomas Oliphant is a Globe columnist.
