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THOMAS OLIPHANT

Healthcare deadbeats

WASHINGTON

SENATOR EDWARD M. Kennedy came up with an idea the other day that could nudge the debate over the country's worsening health insurance crisis both nationally and in Massachusetts.

Why not have the states publish lists of large employers (50 workers or more) who have full-time people receiving publicly financed healthcare like Medicaid and the program that helps insure children of the less well-off? Fifteen states already do so.

In some cases, the shame of being so identified might induce changes in corporate behavior. In others, knowing more about the full-time workers who need Medicaid and Children's Health Insurance Program assistance might help states devise programs that can produce universal coverage.

Massachusetts is one place where the uninsured percentage is low enough that public policy aimed at assisting individuals can almost certainly fill the gap.

If states were required to assemble such facts, the result would shine multiple lights on a crisis that gets worse every day in the form of soaring costs and dwindling availability. It would identify the companies whose bottom lines allow for workers' benefits, those for whom the cost already is prohibitive, and it would help identify workers whose low incomes make employer-provided insurance out of the question because of the premiums, co-payments, and deductibles in existing policies.

The legislation -- Kennedy's co-conspirators are Democrats, Senator John Corzine of New Jersey and Representative Anthony Weiner of New York -- is aimed at monsters like Wal-Mart, infamous for its luscious benefits for company big shots and nonexistent coverage for ordinary employees, whose insurance is the left to taxpayers. The most common estimate is that more than 600,000 Wal-Mart employees, nearly half of its workforce, have to use public safety-net programs.

What Wal-Mart doesn't do, out of profits that total $10 billion or so, costs taxpayers more than $200 million to provide -- including $61 million in Florida and some $3 million in Massachusetts. In 12 states Wal-Mart is the largest employer with workers on Medicaid and other assistance programs. The fact remains, however, that half the uninsured in Massachusetts and in many other states work at outfits with fewer than 25 employees.

In states where the percentage of uninsured is especially high (the national average is above 15 percent), a state solution would appear prohibitively expensive. But in places like Massachusetts, where the total is less than half that, the opportunity to get to universal coverage is much more possible.

With a target population of perhaps 460,000, major political players are weighing in with ideas that have a shot at legislative enactment this year, while a constitutional amendment establishing a right to insurance moves toward next year's ballot. Governor Mitt Romney, Senate President Robert Travaglini, and a coalition of activist organizations have all weighed in, and the similarities are more striking than the differences.

As a report for the state's Blue Cross/Blue Shield foundation makes clear, the options are a mix of direct subsidies, tax credits, public re-insurance, and regulatory requirements. Before figuring the economic and health benefits of universal coverage, Massachusetts appears to be more than $1 billion a year short of the resources to do this.

An outsider is struck by the shift in consensus opinion away from the mandate on employers. Clearly different strategies are required for different groups of the uninsured -- for the 106,000 already eligible for Medicaid but not enrolled, for the 150,000 working but uninsured people who have 100-300 percent of the official poverty level as their income, and for the 200,000 whose income is more than three times poverty.

Wal-Mart and its ilk deserve public opprobrium. In other states, full disclosure of the extent to which they foist full-time workers into public health insurance programs should lead to mandates.

In Massachusetts, however, it should lead to some stiff, compensating fees, but the job of making coverage universal can be accomplished without them. Instead, communities contemplating revenue-losing deals with new Wal-Mart stores might want to think about the large pile of money bad corporate citizens also cost taxpayers via healthcare stinginess.

Thomas Oliphant's e-mail address is oliphant@globe.com.

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