He didn’t come to St. Louis to walk the fault line in modern medicine. But that’s essentially what happened when Sen. Barack Obama, the presumptive Democratic presidential candidate, visited with cardiac patients at Barnes-Jewish Hospital last week.
Cardiac care units like the one he toured are where the incredible technological prowess of modern medicine comes face to face with some of its most fundamental and intractable problems.
One of those problems is cost, and cost was at the center of Mr. Obama’s public remarks, and of the Republican response. Mr. Obama touted his voluntary national health insurance plan that he said would make care more accessible and affordable to millions of middle-class Americans. His presumed opponent, Sen. John McCain of Arizona, has criticized Mr. Obama’s proposal as expensive and unwieldy.
But without reasonably good health insurance, the cost of the medical miracles that are performed at cardiac centers like the one at BJH are out of reach for a growing number of Americans.

Americans spent a collective $76.5 billion to treat heart problems in 2005. That’s more than the combined total spent on diabetes, high cholesterol and infectious diseases such as AIDS.
The largest single share of spending on heart problems, $48.4 billion, was for care delivered in a hospital. That covers some of the most dramatic procedures modern medicine has to offer, and also some of the costliest.
On the day Mr. Obama made his Barnes-Jewish tour, the journal Health Affairs reported that between 2003 and 2007, the number of people with inadequate insurance coverage grew by 60 percent. In total, researchers reported, 42 percent of U.S. adults are either uninsured or under-insured — that is, they have out-of-pocket medical expenses greater than 10 percent of their income.
Most of the newly under-insured are working families earning more than twice the poverty level, about $34,340 for a family of three. Many became under-insured when their employers’ health benefit plans began to impose higher deductibles and greater cost-sharing.
Higher deductibles and cost-sharing are exactly the kind of changes that conservative groups and Mr. McCain tout as cures for runaway health spending. Mr. McCain would encourage more people to buy health insurance on their own, instead of getting it as a benefit at work. He also champions medical savings accounts that make people responsible for a bigger share of health costs to reduce “unnecessary care.”

But as Mr. Obama no doubt saw during his visit to Barnes-Jewish Hospital, not much “unnecessary care” goes on in cardiac care units. Patients there are very sick; the care they receive is a life-saving necessity few could afford on their own.
The real effect of higher deductibles and greater cost-sharing is to make people delay getting care until their health problems are more advanced — and, therefore, more difficult and expensive to treat.
Insurance works best when it allows the greatest number of people to pool their risks. Not everyone has the same degree of risk. But they receive the same protection. That’s why a national health insurance program like Medicare makes sense.
Mr. Obama’s plans falls short of that. It wouldn’t provide universal coverage, for example, which is where real economic efficiencies occur.
But his idea of widening the insurance pool and protecting the growing number of families who face economic disaster should serious illness strike is a big step in the right direction.

(J. B. Forbes/ Post-Dispatch photo)