Raleigh

As they speak about their health-care proposals, don't expect any of North Carolina's major gubernatorial candidates to mention this little fact: Nearly 25 percent of the average American's lifetime medical costs will come in the final days of life.

It's a vexing statistic, one that gets to some of the root causes of escalating medical costs but also leads to all kinds of ethical quandaries. For political candidates, wading into the fundamental questions raised by this fact hardly lends itself to 30-second sound bites.

The candidates for governor, Republican and Democrat, are talking about health care. A recent debate focused on the topic, and all have come up with proposals that each touts as providing better care, cutting costs or both.

Democratic Lt. Gov. Beverly Perdue is calling for an expansion of health insurance programs for the poor and working class, with some cost-sharing by families based on their income level. She also wants to provide tax incentives to small businesses so that more will provide health insurance to workers.

Perdue's Democratic rival, State Treasurer Richard Moore, has proposed insuring all children in the state, using the same kind of expansion of existing programs envision by Perdue. He talks about incentives to try to hold down health care costs.

Not surprisingly, the four major Republican candidates focus more on market-based approaches.

State Sen. Fred Smith says empowering consumers to make choices, with health savings accounts, can improve the system. He also is pushing medical malpractice reform as a way to curb "defensive medicine."

Former Supreme Court Justice Bob Orr believes the state needs more doctors and other health care providers to improve access to care and create more competition. He wants to give consumers more information about the costs of services so that they can make more informed decisions.

Salisbury lawyer Bill Graham believes the state can expand on high risk pools, with businesses, associations and unions banding together to insure employees with pre-existing conditions. He also wants to provide incentives to employers who offer employee programs designed to prevent illness.

Charlotte Mayor Pat McCrory also talks about lawsuits driving up the costs of health care, and says illegal immigrants are putting a strain on the system.

If you throw all the ideas together and pluck out the best ones, some would result in better care and hold down costs. The market-based approaches by Smith and Orr would help. The ideas from Perdue and Moore would lead to better care -- creating savings in some areas and added tax expense in others.

Still, all these ideas nibble at the edges.

We live in a country that has seen medical costs rise from 8 percent of income in 1987 to 20 percent of income today, a place where per capita spending on health care is 47 percent higher than any other country. It's a country where technological innovation drives up costs and people's expectations.

In politics, you feed those expectations. You don't curb them.

Scott Mooneyham writes for Capitol Press Association. Contact him at smooneyh@ncinsider.com