If Wal-Mart were a state, it would rank 39th in population, right behind Nebraska -- and that doesn't include the dependents of the company's 1.7 million employees.

This company doesn't negotiate discounted prices from suppliers of everything from panties to popcorn; it mandates them. Wal-Mart makes unions tremble and politicians swoon. It could grab a health-insurance provider by the throat, shake it a few times for effect, then swing the sweetest healthcare coverage deal in the universe.

But why should it, when it can pass its health-insurance costs to taxpayers?

Maryland made a first bold attempt to put a stop to this cold, corporate calculus last week when it passed a law (over the governor's veto) requiring any company with more than 10,000 employees in the state to spend 8 percent of its payroll on employee health insurance or to pay the difference to the state Medicaid fund to help cover low-income state residents. Only Wal-Mart meets those parameters.

I'm not a lawyer, but I've been in enough casinos to know where I'd place my money in a contest between Maryland's state attorneys and the legal titans Wal-Mart will throw at them. But at least Maryland's legislators tried. What a concept -- public policy on behalf of the public!

For all of its myriad other real and imagined evils, Wal-Mart isn't the cause of the nation's health-insurance crisis, only the most salient evidence of it. Wal-Mart is doing exactly what profit-driven private corporations will do when we leave what should be public policy in their hands: Maximize return and minimize costs, regardless of who suffers. Corporations aren't about compassion, they're about market efficiency. We shouldn't condemn a snake for being a snake.

It's a sad accounting for the world's richest nation: 45 million Americans, including 8.4 million children, lacked health-insurance coverage in 2003, according to the National Coalition on Health Care (whose honorary chairmen are former presidents Bush, Carter and Ford). The Coalition projects that the number of uninsured could reach 53.7 million in 2006 -- an increase of 10 million since President Bush took office in 2001.

Coverage is costly.Those lucky enough to have health insurance are paying dearly for it: If 2006 projections are correct, the average cost of employee-sponsored family health insurance will have doubled to $14,565 since 2001 -- so much for your middle-class tax cuts. And the employee's share of those costs has shot up 126 percent since 2000.

The result is that the best medical technology reaches too few people. ''The American healthcare system provides excellent care to many of its patients much of the time, but . . . not to enough of its patients enough of the time,'' the Coalition observed in its 2004 report, Building a Better Health Care System (available at http://www.nchc.org/materials/ studies/reform.pdf).

We're in this crisis because the American public has been snake-charmed into believing that legislation in the public interest is an insidious, reprehensible enterprise, and that nothing is good for America unless the Fortune 500 has extracted every last penny of profit from it. That's how we ended up with a Medicare bill that confuses consumers but rewards pharmaceutical companies, and an energy policy enabling Exxon-Mobil to earn $10 billion in a quarter while heating oil and gasoline prices soar.

In the early 1990s, the Clintons were mercilessly skewered by conservatives for at- tempting to open up a public policy dialogue on healthcare coverage. The resulting chill continues; the topic has replaced Social Security as the ''third-rail'' issue politicians dare not touch.

We can cover every American, contain costs and spread them more equitably, improve access and simplify administration, but we'll have to overcome our collective aversion to debate. Everything -- from privatization to socialization, and all in between -- should be on the table.

But I have a bad feeling that campaign 2006 will be preoccupied with some other issue -- I'm guessing immigration -- that will succeed in distracting voters and pushing this issue into the background again. And we'll go on hoping that nagging pain, or that persistent cough, will go away on its own.

Email to: rsteinback@MiamiHerald.com.