November 17, 2003

AT A BRAINSTORMING session last week on expanding access to health care in Maryland, there was a palpable longing for a solution that somehow wouldn't cost anything.

Trim the bureaucratic fat, get people to avoid risky behavior, squeeze more out of the feds (as though federal taxpayers don't include Marylanders) - those were among the notions proposed.

The lawmakers present were more realistic about the tough choices required to extend primary and preventive care services to the 690,000 Marylanders without it: You can't get there from here unless somebody pays.

The goal is to make the overall health insurance system both more efficient and more humane, but the means to achieve that are expected to be such a tough sell that politicians favor a piecemeal approach.

And that's probably the wisest course anyway. Maryland's health insurance system is already a patchwork of public and private, state and federal, employer-based and individually financed. It's easier and less risky to fill in the holes incrementally than to undertake a major redesign.

Advocates of the Health Care for All plan, widely credited with focusing renewed attention on the plight of the uninsured, are impatient for a comprehensive solution. Their proposal to finance new benefits in part by taxing Maryland employers who don't offer health insurance to their workers has been useful as a bargaining position. It has already prompted Gov. Robert L. Ehrlich Jr. to begin shaping an alternative package based on tax credits that he plans to offer after the state resolves its current budget crisis.

While it makes sense not to attempt too much in the General Assembly session ahead, rapidly rising medical costs as well as the growing ranks of the uninsured suggest state officials should be as ambitious as possible.

A good first installment would include a combination of cost savings and expanded access to care. Health Secretary Nelson J. Sabatini wants to use the state's purchasing power to negotiate discounts on pharmaceuticals and tighten the limits on medical malpractice awards. Such steps might be part of a package that also increases services available at community health clinics and raises the income thresholds for Medicaid eligibility, potentially by reducing some of the state-mandated benefits.

Inevitably, making health care services more broadly available requires a balancing act. The haves - taxpayers, employers, medical providers, drug companies, malpractice lawyers - will be asked to yield something to the have-nots. But a healthier population will result in savings all around.

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