Prognosis for the uninsured: state lawmakers are still trying to do something about the millions of Americas without health care coverage, but the solution remains elusive.

• Author: Tobler, Laura

[ILLUSTRATION OMITTED]

This is the second in a series on the health care policy issues faced by state lawmakers. Next month the magazine looks at telemedicine.

The number of Americans without health insurance is staggering: nearly 46 million when the Census Bureau last counted in 2004. And the number is rising.

Americans pay more for their health care than people in any other nation. The rising cost has squeezed small employers out of the market in many instances, and increased the cost to large employers--and their employees--significantly. In fact, the number of firms offering health insurance has declined substantially, from 69 percent in 2000 to 60 percent in 2005, according to the Kaiser Family Foundation. Although premiums rose by only 9.2 percent from spring 2004 to spring 2005, a single digit increase for the first time in several years, it was still nearly triple the rate of inflation. Since 2000, premiums for family coverage have increased by 73 percent at the same time inflation grew by 14 percent and wages by 15 percent, according to Kaiser.

Yet despite this cost--and because so many people go without insurance--Americans rank poorly with the rest of the world in several health indicators. We don't live as long as the Japanese, or people in Iceland, Spain, Switzerland or 18 other countries. The United States is 23rd in life expectancy.

More than a decade has passed since the Clinton administration's universal health care proposal was repudiated. Yet the problems that inspired national reform then still exist today. And those problems are being dumped on the states.

It is little wonder that interest in health care reform is growing in the states. The ideas and magnitude vary state to state, but the goal is the same: improve access to quality health care.

IN PURSUIT OF UNIVERSAL HEALTH CARE

Most state reforms have been incremental measures that affect only certain groups. However, a couple of states--Maine and Massachusetts--are marching toward universal coverage.

Maine's 2003 Dirigo Health Reform Act, which was honored by Harvard's Ash Institute as one of the top 50 government innovations for 2006, aims to provide every citizen access to health care by 2008. Trish Riley, director of Health Policy and Finance in the governor's office, says the broad reforms include a new health plan called "DirigoChoice" that anybody can buy into; a new health system designed to improve quality and lower costs; and an expansion of the state's Medicaid program to cover more of the low-income uninsured.

Maine continues to move forward, but the path has been rocky. "The opposition to the program has been ferocious by those that support private market initiatives," says Riley. In addition, the insurers who originally supported the program are now suing the state over one of the financing mechanisms. Despite these troubles, 15,000 people have been enrolled since January 2005. Of those, over 43 percent were previously uninsured and almost 60 percent were underinsured.

Massachusetts tackled universal coverage this legislative session making it the first state to provide health insurance for nearly all citizens.

"HB 4479--the Promoting Access to Healthcare bill--spreads the responsibility for financing health care among government, employers and individuals," says House Speaker Salvatore DiMasi. The measure includes a Medicaid expansion, state insurance subsidies, creation of an entity called the "Connector" to facilitate the purchase of insurance by individuals and small employers, and a requirement for individuals to buy insurance or face possible penalties.

"Under this model of...