States Scrambling to Discover Ways to Get Health Coverage for Everyone

Pushed by growing public concern about the medical care problems of the poor and uninsured, states are scrambling to come up with ways to bring more people into the health care system without sending costs into the stratosphere.

These proposals generally fall into two categories. One set seeks to fill gaps in the current multiple-payer system, which consists of private insurance companies, government programs such as Medicaid and Medicare, and various stopgap state programs that fund health care for special groups such as children and pregnant women. This set of proposals would scrap the current system altogether, pooling money from all of these programs in one state-administered insurance plan providing comprehensive medical coverage to all of the state’s residents.

There are also proposals by organizations outside government seeking to address the plight of the nation’s estimated 35 million uninsured. The American Medical Assn. recently devoted a special issue of its journal to showcasing 15 insurance reform measures proposed by labor, business coalitions, physicians and other interest groups.

BACKGROUND: But state budget deficits are hampering reform in many states. California won’t consider any this year because of the looming $14.3-billion deficit.

In Massachusetts, a 2-year-old state fund to pay hospitals for care of the uninsured is jeopardized by that state’s budget deficit. Gov. William F. Weld is proposing to save $154 million by eliminating next year’s contribution to the fund.

Even Hawaii, with a long history of activism on behalf of the uninsured, has money problems. Although the state has pieced together insurance programs for virtually all of its residents, hospitals say that some reimbursement rates are so low they are being forced into the red.

These difficulties notwithstanding, public pressure is mounting for reform statewide and nationally.

A recent poll of Californians by the Gallup Organization showed widespread concern about the plight of poor and uninsured patients and profound dissatisfaction with political leadership on the issue. The poll indicated strong resolve among constituents to contribute to a solution through higher taxes--if the leadership were there.

Rhetoric is heating up, too, and not just on the part of traditional advocates for the poor. If only because of its reputation for conservatism, the AMA’s special journal issue on insurance reform proposals and the accompanying editorial calling for government action struck many as significantly emphasizing health insurance reform on the national agenda.

Journal editor George D. Lundberg cited the crumbling of Soviet dominance in Eastern Europe and Abraham Lincoln’s moral stand against slavery as parallels to the challenge of guaranteeing Americans basic medical services.

“If the Iron Curtain can be lifted, the Warsaw Pact dissolved, and East and West Germany politically reunited, all quite rapidly because it was the right thing to do and the time had come,” Lundberg wrote, “surely we in this rich and successful country can manage to provide basic medical care because it too is the right thing to do, and the time has come.” But has the time come politically? Some observers are skeptical.

At least 14 state legislatures are considering single-payer, government-administered health insurance systems. But it is a radical concept for this country, involving scrapping the entire network of private insurance companies most Americans rely on for coverage, usually as a job benefit.

Political observers give better odds to the patch-up proposals involving, among other measures, insurance underwriting reform, controls on spending and government subsidized insurance pools for small businesses and individuals currently priced out of health coverage.

How quickly such reforms might occur is also the subject of debate.

OUTLOOK: E. Richard Brown, a professor of public health at UCLA, does not believe there will be significant reform at the national level for two to four more years.

“Business has to hurt a little more under the pressure of these costs, this recession has to ease up and we need some leadership in the White House,” he said.

In the meantime, states will serve as laboratories to test what might sell nationally, according to W. David Helms, director of the Robert Wood Johnson Foundation’s Health Care for the Uninsured Program.

“Some states will mandate coverage, like Hawaii, some states will set up programs to fill in the gaps in coverage,” Helms said. “My guess is that out of some of these various efforts will come the seeds of how we can fashion a national plan.”