If the United States weren’t at war and if more attention were focused on the domestic front, there can be no doubt what one of the top issues would be right now:

Health care reform.

Heath care is hitting Americans hard in the pocket once again. Those who have been lucky enough to hold on to their jobs and get raises face the real possibility of taking a financial step backward in 2002 as insurance premiums jump once again.

And soaring unemployment brings double bad news for many families. They lose not only their paychecks, but also their health insurance, since continuing premiums are nearly always too costly for the unemployed. Worst-case scenarios being spun on Capitol Hill right now peg the number of uninsured Americans at 39 million.

In some respects, this is deja vu. When Bill Clinton won his first bid for the White House in 1992, his supporters taunted then-President George H.W. Bush with chants of “It’s the economy, stupid.” Rising health-care costs and unemployment had driven the number of uninsured Americans to 37 million, and Bill and Hillary Clinton put health care reform at the top of their agenda.

The Clintons’ complex approach to reform got nowhere in Congress, but the sudden attention to health-care costs pushed related industries —particularly the insurance industry —into a period of rigorous self-reform. HMOs, PPOs and other variations on the theme attempted to manage costs while maintaining good patient care. But such plans have proved to be only a temporary fix. A good many HMOs have fallen by the wayside. Several experimental approaches to managed care have come and gone. Now health insurers are jacking their prices once again — spooked, perhaps, by patients rights laws that threaten the autonomy of their decision-making, and prompted by the aging Baby Boomers’ growing health-care needs.

You don’t hear talk yet of sweeping reform. Sen. John Edwards, in a recent release to newspapers, advocated several measures to strengthen health-care options for the poor and unemployed, particularly when it comes to children.

And, like many, Edwards is touting a strong prescription drug benefit within Medicare, to take care of the elderly and their soaring prescription drug costs — a hot topic of the 2000 presidential race that has faded into the background since Sept. 11.

So far in this decade, no one has championed middle-class workers and the way health insurance threatens to shrink their paychecks. Perhaps the symptoms are not severe enough yet. But the suffering of the unemployed cannot escape attention. Thirty-nine million uninsured people sounds like a disaster waiting to happen —for them, their families and their communities.