WASHINGTON -- Health care reform may be dead in Washington, but a growing number of states - under Republicans and Democrats alike - are taking steps to expand medical insurance coverage.
Faced with a problem they find increasingly hard to ignore, governors and legislators in at least 20 states have hammered out agreements to expand access to health care by squeezing money from existing health programs and taking other politically difficult steps, including tax increases.
In Illinois, Democratic Gov. Rod R. Blagojevich is about to sign a bill providing affordable health coverage for uninsured children of working parents. And Massachusetts has taken on a much bigger challenge. There, Republican Gov. Mitt Romney and the Democrat-controlled Legislature are negotiating over competing plans to cover all of the state's half-million uninsured residents.
"The fact that nothing is happening in Washington is not deterring states," said Alan R. Weil, executive director of the National Academy for State Health Policy. "The lack of action in Washington is not because of the lack of a problem. It's because of a lack of agreement and, frankly, a lack of consequences for failing to address the issue. At the state level, if you have a Medicaid budget problem or a growing number of uninsured, you have to tackle the issue."
Given the seemingly intractable economics of health care, it is not clear whether the states will be able to sustain the efforts they have started. Controlling costs continues to be difficult. States' revenues can fluctuate. And many are legally barred from running deficits.
But traditional employer-based coverage, the cornerstone of the old system, continues to shrink as the average cost of a family plan approaches $11,000 a year. And some experts think the modest but growing efforts by states could help jump-start a national debate.
"If any of these states succeeds, it could provide impetus for a national debate in later elections," said Robert Blendon, a public opinion analyst at the Harvard School of Public Health. "If the Iraq war and terrorism were to go away, health care issues are going to pop right up because they just bother a lot of the public and voters."
Earlier this year, headlines focused on Medicaid cutbacks in Tennessee and Missouri, which are expected to leave tens of thousands without coverage. And Florida's experiment with managed care for its poor is being watched warily by liberals.
But a study by the Kaiser Commission on Medicaid and the Uninsured, released in October, found that 20 states increased access to health care in the 12 months that ended in July. In nine states, those expansions reversed previous cuts. For example, Texas rescinded premium increases that had contributed to 149,000 low-income children losing coverage. Fourteen states took action that had the effect of limiting health care access, in most cases by raising premiums for programs covering low-income children.
The Kaiser study found that more states are expanding coverage because budgetary pressures have eased somewhat.
Romney backs a proposal requiring that people obtain health insurance, much as they are required to have automobile insurance. People could enroll in an employer or government plan, or purchase a policy. Subsidies would be provided for those with low incomes.
Some conservatives see such an insurance mandate as tantamount to a tax increase.
Romney is also at odds with many Democratic lawmakers, who believe that employers should be the ones required to provide coverage. The Massachusetts debate may extend into next year, but activists on both sides say the chances for a deal appear good.
"I think it is likely that we are going to do something here, even though nothing is happening in Washington," said Richard C. Lord, president of Associated Industries of Massachusetts, a business federation trying to stop an employer mandate.
"Most people think something significant is going to happen," said John E. McDonough, director of Health Care for All, a consumer group.
Other states have opted for a more limited strategy, focusing on small businesses that employ low-wage workers.
Oklahoma, for example, recently started to enroll small companies and their employees in a program that will subsidize premiums for private health insurance. The effort is largely financed by a tobacco tax increase that state voters approved last year.
Ricardo Alonso-Zaldivar writes for the Los Angeles Times.