Those waiting for the federal government to take the lead on helping the uninsured are either hoping for a sea change in control of Congress and the White House or have a lot of time on their hands.
As this week's cover story shows, the action has switched to the states, where some lawmakers still know how to work across the aisle and where governors want to do more than appear to lead.
Where Congress can help is by getting out of the way, something it isn't very good at. A new study in Health Affairs of 10 states' Medicaid waivers found that in eight of those states, coverage was expanded and benefits weren't cut. That's a good thing. But a bill moving through the Senate is designed to undercut decades of state actions to expand coverage.
Deceivingly called the Health Insurance Marketplace Modernization and Affordability Act, this ingenious Trojan horse for health insurance deregulation is sponsored by Senate Health, Education, Labor and Pensions Committee Chairman Mike Enzi (R-Wyo.). His plan, already passed by his panel, ostensibly seeks to allow small businesses to band together to offer affordable health insurance to employees. But it also would set aside state regulations that force insurers to cover people with pre-existing conditions; charge everyone reasonable premiums; and cover needed services such as mental health, well-baby care, mammograms and prostate cancer tests. The pre-emptions would apply not only to small-employer plans but also to individual health insurance and large-group plans.
Meanwhile, states are busy actually trying to get people coverage. The most far-reaching plan to become law is Massachusetts' near-universal coverage effort. Talk about bipartisanship. GOP Gov. Mitt Romney got the ball rolling but the Democrat-controlled Legislature, Sen. Edward Kennedy and a wide range of interest groups worked to pass it.
It isn't perfect. There will be a long period when major issues need to be worked out, such as whether insurers are ready to provide minimally acceptable coverage for reasonable rates and whether an individual mandate will really get those with marginally higher incomes to buy coverage. It's too early to call this a success, but it is a well-intentioned effort that must be given time to work.
Massachusetts' plan is more far-reaching than Maine's 3-year-old Dirigo Health initiative, a public-private partnership designed to cover some 130,000 state residents by 2009. Both plans seek to control runaway healthcare costs through various quality initiatives.
A number of other states also are set to follow suit, notably Illinois, which last year passed legislation to cover all children in the state. A task force has been holding meetings across Illinois and must report its findings by the end of this year. Under current law, a universal coverage bill must be passed by July 1, 2007. With 1.8 million uninsured in that state, or three times the level of Massachusetts, the challenge is daunting.
In West Virginia, the Legislature and governor got together to create a new law committing the state to providing health coverage for all residents by 2010, an effort that starts with a new health clinic plan next year.
Meanwhile, California, Connecticut and Hawaii are examining single-payer systems.
It makes you wonder why Washington hasn't seized on healthcare as a national priority. Tommy Thompson, who quit as HHS secretary last year, is now pondering a race for president, with healthcare as issue No. 1. The growing uninsured population is "a real emergency" Congress isn't addressing, he told the online publication CQ HealthBeat. He adds that he sought to make healthcare a leading priority of President Bush's second term but was rebuffed by the White House "palace guard," which was more interested in Social Security reform.
Looking at what happened with that effort, maybe it's best Washington has left healthcare to the states.