The bleak future and the precarious present for Wal-Mart workers was nicely summarized in a memo to the company's Board of Directors that was made public last week. Written by a corporate vice president, M. Susan Chambers, the memo discusses the company's health care benefits package with stark honesty. Health care for hourly workers, the memo acknowledges, "is one of the most pressing reputation issues facing Wal-Mart."

The memo explores how the company can encourage healthy behavior in its work force. That's a very good thing. It also mentions a plan to open clinics in stores, and how to teach workers about the most efficient ways of getting health care.

But the memo also lays bare the cold calculus of benefits and wages. The result should be eye-opening for everyone, no matter where they work: Where the nation's largest retailer leads, others will follow.

This is where it's leading:

About half the children of Wal-Mart employees are either uninsured or covered by government-subsidized insurance such as Medicaid. Nationally, about one-third of all workers' children are uninsured or covered by government-subsidized programs.

About 20 percent of Wal-Mart workers have no health insurance at all. About 5 percent of the company's workers earn so little that they qualify for Medicaid, the state-federal health insurance program for poor people.

Wal-Mart executives were alarmed to discover that "the least healthy, least productive" workers are "more satisfied with their benefits ... and are interested in longer careers at Wal-Mart." Most of the company's "unacceptable" growth in the cost of health care benefits is driven by "increased utilization" — that is, by people actually using those health benefits.

The poorest and sickest workers have the highest out-of-pocket health expenses. On average, Wal-Mart workers with health insurance pay twice the national average for out-of-pocket health care expenses. About 40 percent of the company's insured workers paid four times the national average, or 16 percent of their income, for out-of-pocket health care expenses.

Among other things, the Wal-Mart memo proposes changing job descriptions "to attract a healthier, more productive work force" — e.g. hiring fewer old or physically disabled people. It also suggests moving employees to so-called defined benefits programs, like health savings accounts. That would be good for Wal-Mart, which would know its future benefits costs with certainty. But it could leave workers more vulnerable; even a modest illness could hurl them into bankruptcy.

Wal-Mart says the changes it proposes actually will increase the number of workers getting health insurance, even if those workers end up shouldering extra risk. But what happens to the older workers who can no longer find a job with benefits, or the low-wage workers who develop illnesses they can't afford to treat?

It's not Wal-Mart's primary job to provide health care benefits for its work force. Its primary job is to make money. With sales of $285 billion, the company's stock is down 15 percent this year on shrinking profits. Still the company made $10 billion in profits last year. But the bad press the company has gotten for its chintzy labor practices has become, as the memo acknowledges, "a reputation issue." They've also been the target of about 40 lawsuits nationwide. Last week, a Missouri judge certified as a class action a 2001 lawsuit accusing Wal-Mart of underpaying workers at its Missouri stores, forcing hourly wage-earners to work off the clock, refusing to pay overtime and denying them rest or lunch breaks.

And now the smoking-gun health benefits memo.

Acknowledging a "reputation issue" is not the same thing as growing a conscience, or developing a corporate ethos that workers should share in company prosperity. PR offensives and transparent misdirection, like Wal-Mart's clean, green environmental initiative, don't address the underlying conflicts.

Wal-Mart's need and desire — shared by employers throughout America — to control rising health care costs butts up against the inadequacy of the public safety net. Many cash-strapped states have slashed their Medicaid rolls, forcing tens of thousands more working men and women into the ranks of the uninsured. Between 2000 and 2004, 6 million Americans lost their health insurance.

In effect, government has defaulted. That leaves workers in the lurch and leaves the hard choices about health care to companies that must wring out expenses to keep prices low for consumers and profits high for shareholders.

That isn't problem-solving; that's problem-shifting. But never mind a national health care policy; we can't even have a national health care debate.

The sooner that business, government and labor come together to thrash out a plan, the better for everyone. Because the only way out of this swamp is through it.