Health care: feds fight, states act: lawmakers were experimenting with ways to rein in costs and expand coverage long before passage of federal health legislation.

• Author: Brand, Rachel
• Position: Cover story

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Insurance reform. Medicaid expansion. Mandates. For months, federal lawmakers-and ordinary Americans--have been debating a national overhaul of our health care system.

Yet without media fanfare, state legislative leaders have been quietly working on their own versions of health care reform. That's because even with federal action, states face relentless fiscal pressure.

Medical providers are overwhelmed, and the number of uninsured is growing. Democrats and Republicans agree we cannot afford the current inefficient, expensive and inadequate medical care system.

Interviews with five legislators deeply concerned about health care--two Democrats and three Republicans--found some hope that federal reform would help their state cover more uninsured. Others vowed to proceed with market-based reforms, however, despite passage in March of a federal overhaul, and hoped national reform wouldn't supersede their work.

State Legislatures asked leaders to define their state's most pressing health care problem and reflect on how the federal government could help them achieve health care goals. They also discussed the best means to provide health care to more citizens, and what they were doing to reform their state's health care systems.

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IT COMES DOWN TO COST

Across the nation, leaders say that skyrocketing health care costs are walloping family budgets and pushing state finances to the brink.

"Like every other state, our most basic problem is controlling the rapidly expanding costs of health insurance," says Oregon House Speaker Dave Hunt. "When employers and individuals see double digit increases year after year, and the share of insurance premiums takes a bigger bite out of business, family and public income, controlling those increases is critical to the health of our health care system."

Underlying medical cost inflation, of course, are both technological innovation and a rising need for services. Ron Ramsey, Tennessee's lieutenant governor and Senate speaker, sees getting individuals to prevent illness before it happens as the state's biggest challenge.

Tennessee's largest hurdle is "figuring out how to get people to take personal responsibility for their health," he says. "More than 30 percent of our population is obese, and obesity is a trigger for a variety of chronic medical conditions, such as diabetes, heart disease, orthopedic disorders, even cancer."

Medicaid's increasing share of state bud gets is also a cause of deep concern.

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The state-federal health care program for the disabled, poor children and low-income pregnant mothers covers 60 million Americans.

Medicaid spending rose 7.9 percent in FY 2009 while enrollment rose 7.5 percent, the...