LJWorld.com

Health care for all - an elusive goal that has tantalized presidents and governors for decades - is roaring back this year with ambitious proposals in a handful of prominent states.

The promise: Cover millions of uninsured adults and children. Improve the quality of care at hospitals and doctor's offices. Rein in rising costs that are eating up workers' wages, company profits and state budgets.

The problem: Someone's got to pay. And getting those with a stake in health care - doctors, insurers, hospitals, workers, employers, government - to agree on who and how much won't be easy.

The most influential effort is undoubtedly in California, the nation's most populous state, where GOP Gov. Arnold Schwarzenegger this month introduced a bold plan that would provide health care coverage for 6.5 million residents without insurance.

With less fanfare, Pennsylvania has proposed a similar step and a half-dozen more states are actively debating the idea. All are building on a Massachusetts program that began this year - it likens health insurance to car insurance, making it a requirement for everyone.

If successful, the states could carve out a long-sought path for universal health care, a goal that's been politically dead since the Clinton administration. But that's a big "if" - passage won't be easy and the programs aren't cheap.

The Associated Press looked at proposals in front of state legislatures to break down the contentious issue.

Hot issue

It's been talked about and debated for years, but wide agreement is emerging over the problem of health care's rising costs, which swallow wage increases and have threatened to overtake state spending on primary education. Businesses say they're at a disadvantage with global competitors.

The system can't survive another few years on the same track without collapsing, said Pennsylvania Gov. Ed Rendell, a Democrat.

"If California, Pennsylvania and Massachusetts prove it's doable - and Maine has already to some extent - it will create an unstoppable momentum," he said.

Maine brought the issue back in 2003, with a law seeking to provide universal coverage.

Massachusetts' law last year - guaranteeing universal coverage - jump-started the action in state capitols.

In the last month, governors, legislative leaders and blue-ribbon commissions have declared universal coverage an attainable goal in Iowa, Kansas, Minnesota, New Mexico, Oregon, Washington state and Wisconsin. Massachusetts and Vermont are to put their programs into effect this year, while Maine is tweaking its existing system. Many more are considering significant expansions.

How it would work

The overall goal is to get everyone, or nearly everyone, health insurance. The plans also aim to cut costs by improving efficiency and to improve the quality of care. The plans being discussed would accomplish that in the following ways:

¢ All would build on the existing public and private insurance system to provide insurance and health care access to most or all the uninsured in their states - now some 46 million people nationwide.

¢ All aim to expand existing Medicaid programs to cover more of the poor and working poor who don't have insurance. They would require employers who don't provide insurance to do so. They seek some financial contributions or savings from doctors and insurers.

¢ They would establish a state mechanism that creates an insurance product, or sets up a marketplace, so that small businesses and individuals can get reasonably priced insurance.

¢ Some plans mandate that every individual must have insurance - not unlike mandatory auto insurance for every driver - with financial help for those too poor to buy it outright.

Biggest barrier

The biggest stumbling block is money. Who pays?

In California, doctors and hospitals already are unhappy with Schwarzenegger's plan to levy a 2 percent fee on doctors and a 4 percent fee on hospitals. He would cap profits for insurers by requiring that 85 percent of revenue be devoted to treating patients. That idea alone sent the stock of health insurer Wellpoint Inc., with 34 million members, down 3.5 percent.

"He made enemies of every doctor and hospital in California when he did that," said Helen Darling, president of the National Business Group on Health, a consortium of companies trying to lower health costs.

In California, Pennsylvania, Massachusetts and Maine, state leaders said they were spreading the pain to every player, so every critic should stay on board.

"That's always been the biggest challenge in health care reform. There is no pain-free solution," said Drew Altman, president of the Henry J. Kaiser Family Foundation, a Washington-based health group.

Chance of success

The next few months will determine whether enthusiasts like Rendell or Schwarzenegger win the argument.

In Minnesota, GOP Gov. Tim Pawlenty warns that simply focusing on getting everyone insurance ignores deeper problems, even as some leaders of the Legislature's new Democratic majority say this is the year for universal health care.

"Many policymakers around the country are so fixated on more access, they're losing sight of the need to simultaneously focus on cost and quality," Pawlenty said. "Expanding access to a broken system is no solution. ... In the long run, that will be a failure."

He wants universal coverage, he insisted, but warns that government can't end up with the bill. His plan would broaden coverage to more uninsured children and have the state create a marketplace where insurers can provide a more affordable product. It wouldn't mandate that everyone get coverage.

There are even deeper philosophical differences in other parts of the country, particularly more conservative states which have emphasized cutting Medicaid costs rather than expanding coverage.

But the new ideas are even getting an airing there.

In Florida, where the biggest health care change under former Gov. Jeb Bush emphasized cutting costs of Medicaid, the new surgeon general talked enthusiastically of Massachusetts' universal health coverage law - and new GOP Gov. Charlie Crist said he wouldn't rule out considering something along those lines.

Flash in the pan?

How the Massachusetts program and high-profile proposals do also will decide the staying power of health care as a political issue. After President Clinton's health care reform attempt failed in the 1990s, the issue went dormant for years.

"Once you pass these programs and start the implementing, it only gets harder," said Maine Gov. John Baldacci, a Democrat. "Because then you're talking about real dollars and real decisions."

Maine hasn't met its ambitious goals, with fewer businesses signing on to the state program. But Baldacci and state leaders are trying to fix the flaws.

"Hopefully," he said, "the chambers of commerce, the unions, the businesses will recognize we need a solution."