Bob Herbert and Paul Krugman are gearing up for the SOTU when W is supposedly going to tell us how to solve the health care crisis. First Bob Herbert on health care costs. Depressing. Then there is Paul Krugman on W’s “solution,” which of course isn’t.

Americans are increasingly living in a house of cards — credit cards.

A disturbing new report shows that with health care costs continuing their sharp rise, low- and middle-income patients are reaching for their credit cards with alarming frequency to cover treatment that they otherwise would be unable to afford.

This medical debt, to be paid off in many cases at sky-high interest rates, is being loaded onto consumer debt that is already at dangerously high levels. Many families have been crushed by the load, driven from their homes, forced into bankruptcy, and worse.

The report, released last week, was jointly compiled by Demos, a public policy group in New York, and the Access Project, which is affiliated with a health policy institute at Brandeis University and is trying to broaden the availability of health care in the U.S.

Imagine for a moment the seriously ill patient who needs to be hospitalized. In the cold new world of health care, the primary message to such patients is often “Show me the money!”

In many instances, of course, the patient does not have the money. What the report found is that even people with health insurance are being drained by health care costs to the point where the credit card seems the only option.

“As deductibles and co-payments increase,” the report said, “hospitals are finding more patients unable to pay their medical bills. Some hospital management analysts are expecting an increase in self-pay patients and are bracing for higher levels of bad debt.

“In recognition of the evolving payment landscape and the risk of hospital bad debt, health care providers are more aggressively seeking upfront collection of co-pays and deductibles. A component of this strategy is to encourage patients to use third-party lenders such as credit cards to pay for medical expenses they cannot afford, which families frequently do to meet high medical bills.”

It’s one thing to reach for your Visa or MasterCard to pay for a Barbie doll or flat-screen TV. It’s way different to pull out the plastic because you’ve just learned you have cancer or heart disease, and you don’t have any other way to pay for treatment that would prevent a premature trip to the great beyond.

A society is seriously out of whack when legalized loan sharks are encouraged to close in on those who are broke and desperately ill.

This medical indebtedness is hardly surprising. Health care costs continue to rise much faster than family income and inflation, and Americans (who have stopped saving altogether) were already mired in staggering amounts of personal debt. Some families have been putting their groceries on credit cards. Many have taken the financially disastrous step of using home equity loans to bring down credit card balances.

A serious illness for people already in shaky economic circumstances can be the final push into bankruptcy.

According to the report, called “Borrowing to Stay Healthy,” about 29 percent of low- and middle-income families with credit card debt reported using their credit cards to pay medical expenses — in most cases for major medical problems.

Over all, a full 20 percent of low- and middle-income families with credit card debt said they had used their cards to cover major medical expenses over the prior three years.

This indebtedness — subject to monthly late fees and penalties, and interest rates that can reach 30 percent — only adds to the trauma of serious illness.

It’s believed that 29 million Americans are burdened with medical debt of one form or another. Individuals who are already saddled with medical bills that they can’t pay are much more likely to avoid further medical treatment and to leave drug prescriptions unfilled. Such decisions often have life-threatening consequences.

There is an epidemic of personal bankruptcies in the U.S. and medical factors are believed to play a role in as many as half of them.

These are problems that cry out for reform — of the American health care system and the American way of debt, both of which seriously threaten the American way of life. At the very least, in the short term, we need to protect financially vulnerable patients from a credit card universe in which there are no legal limits on fees or interest, and where the abuse of customers is the norm.

And Paul Krugman goes down the rabbit hole with W to look at his plan:

President Bush’s Saturday radio address was devoted to health care, and officials have put out the word that the subject will be a major theme in tomorrow’s State of the Union address. Mr. Bush’s proposal won’t go anywhere. But it’s still worth looking at his remarks, because of what they say about him and his advisers.

On the radio, Mr. Bush suggested that we should “treat health insurance more like home ownership.” He went on to say that “the current tax code encourages home ownership by allowing you to deduct the interest on your mortgage from your taxes. We can reform the tax code, so that it provides a similar incentive for you to buy health insurance.”

Wow. Those are the words of someone with no sense of what it’s like to be uninsured.

Going without health insurance isn’t like deciding to rent an apartment instead of buying a house. It’s a terrifying experience, which most people endure only if they have no alternative. The uninsured don’t need an “incentive” to buy insurance; they need something that makes getting insurance possible.

Most people without health insurance have low incomes, and just can’t afford the premiums. And making premiums tax-deductible is almost worthless to workers whose income puts them in a low tax bracket.

Of those uninsured who aren’t low-income, many can’t get coverage because of pre-existing conditions — everything from diabetes to a long-ago case of jock itch. Again, tax deductions won’t solve their problem.

The only people the Bush plan might move out of the ranks of the uninsured are the people we’re least concerned about — affluent, healthy Americans who choose voluntarily not to be insured. At most, the Bush plan might induce some of those people to buy insurance, while in the process — whaddya know — giving many other high-income individuals yet another tax break.

While proposing this high-end tax break, Mr. Bush is also proposing a tax increase — not on the wealthy, but on workers who, he thinks, have too much health insurance. The tax code, he said, “unwisely encourages workers to choose overly expensive, gold-plated plans. The result is that insurance premiums rise, and many Americans cannot afford the coverage they need.”

Again, wow. No economic analysis I’m aware of says that when Peter chooses a good health plan, he raises Paul’s premiums. And look at the condescension. Will all those who think they have “gold plated” health coverage please raise their hands?

According to press reports, the actual plan is to penalize workers with relatively generous insurance coverage. Just to be clear, we’re not talking about the wealthy; we’re talking about ordinary workers who have managed to negotiate better-than-average health plans.

What’s driving all this is the theory, popular in conservative circles but utterly at odds with the evidence, that the big problem with U.S. health care is that people have too much insurance — that there would be large cost savings if people were forced to pay more of their medical expenses out of pocket.

The administration also believes, for some reason, that people should be pushed out of employment-based health insurance — admittedly a deeply flawed system — into the individual insurance market, which is a disaster on all fronts. Insurance companies try to avoid selling policies to people who are likely to use them, so a large fraction of premiums in the individual market goes not to paying medical bills but to bureaucracies dedicated to weeding out “high risk” applicants — and keeping them uninsured.

I’m somewhat skeptical about health care plans, like that proposed by Gov. Arnold Schwarzenegger, that propose covering gaps in the health insurance market with a series of patches, such as requiring that insurers offer policies to everyone at the same rate. But at least the authors of these plans are trying to help those most in need, and recognize that the market needs fixing.

Mr. Bush, on the other hand, is still peddling the fantasy that the free market, with a little help from tax cuts, solves all problems.

What’s really striking about Mr. Bush’s remarks, however, is the tone. The stuff about providing “incentives” to buy insurance, the sneering description of good coverage as “gold plated,” is right-wing think-tank jargon. In the past Mr. Bush’s speechwriters might have found less offensive language; now, they’re not even trying to hide his fundamental indifference to the plight of less-fortunate Americans.