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Los Angeles Times
March 14, 2005
By Ronald Brownstein
In Washington, the debate over reforming the healthcare system
seems to be on life support. The capital has largely turned
the other way as a spiral of rising prices and declining access
has increased the number of uninsured nationwide by more than
5 million since 2000. Proposals now advancing from President
Bush and GOP congressional leaders to cut spending on Medicaid,
the joint state-federal healthcare program for the poor, would
probably push those numbers higher yet.
All of which makes the ferment over healthcare
in California so timely. Almost every conceivable idea to
expand health coverage for the uninsured is on the table in
the state. These include a mandate on employers to insure
their workers, a mandate on individuals to purchase insurance,
a single-payer government-run healthcare system that would
eliminate private insurance and a public-private partnership
to guarantee coverage for all children.
If the state could reach consensus on any
of these approaches--or, more likely, a blend of them--that
could inspire action in other states and eventually encourage
Washington to return to the problem. "This has to get
solved nationally," says Bruce Bodaken, the chairman
and chief executive of Blue Shield of California. "But
a single state solution, as an opportunity for other states
and the federal government to look at what might work, makes
a lot of sense."
The breadth of ideas surfacing in California
underscores the depth of the problem. Figures from the Census
Bureau and UCLA's Center for Health Policy Research show that
about one-fifth of Californians lack health insurance. That's
among the highest rates of any state. The number of Californians
without health insurance (an estimated 6.6 million) exceeds
the entire population of 38 states.
That translates not only into inadequate care
for those without insurance, but also enormous financial pressure
on public hospitals and clinics and higher bills for the insured,
whose premiums must fund the care the uninsured do receive.
An unexpectedly close ballot brawl in November
helped propel healthcare onto the state agenda. With a late
assist from Gov. Arnold Schwarzenegger, business interests
passed a ballot initiative to repeal the mandate that former
Gov. Gray Davis signed requiring employers in firms with at
least 50 workers to insure their employees.
But the repeal initiative won by only 180,000
votes out of 11.6 million cast. That demonstrated a larger
constituency for action on healthcare than many expected.
"We never anticipated coming this close," says
Anthony Wright, executive director of the consumer group
Health Access California. The narrow finish has inspired
the unions and consumer groups that fought repeal to begin
planning their own initiative, probably for 2006, to reimpose
the business mandate.
Meanwhile, a diverse coalition is trying to
build on the state's most promising recent healthcare initiative.
Individual counties across California have imaginatively combined
public and foundation dollars to guarantee health insurance
for all children. An alliance called the 100% Campaign now
wants Sacramento to expand the program statewide--and guarantee
it a permanent source of public funding, perhaps with a private
trust fund as a supplement.
"The counties are not going to be able
to continue what they are doing without a stable financing
source," says Wendy Lazarus, co-president of the Children's
Partnership.
Two other ideas define the debate's ideological
poles. Keith Richman and Joe Nation--a Republican and Democrat,
respectively, in the state Assembly--have proposed legislation
to require all state residents to purchase insurance against
catastrophic healthcare costs. But since that plan would
leave the uninsured--most of them lower-income workers--liable
for the first $5,000 in expenses, many health advocates say
it
"isn't health insurance for people, it's financial insurance
for hospitals," as E. Richard Brown, director of the
UCLA center, puts it.
At the other extreme, Democratic state Sen.
Sheila Kuehl of Santa Monica has proposed a government takeover
of the healthcare system, which still excites many on the
left. But the idea's cost and complexity stamps it as more
a statement of principle than a viable option.
Bodaken says medical, business and consumer
groups are meeting to explore a consensus approach that apportions
costs for universal coverage among business, individuals and
government. That's probably the best option, but insiders
doubt all of the divergent interests involved can agree on
a single plan.
The missing piece in this productive maneuvering
is Schwarzenegger. The governor has expressed some general
interest in several of these ideas. Kim Belshe, his Health
and Human Services secretary, strikes the right note when
she says the administration believes the key to expanding
coverage is to "acknowledge it is a shared responsibility"
among business, government and individuals.
But unless the governor bends his opposition
to new taxes or new mandates on business, he'll lack the resources
for more than modest action. If anything, his fiscal priorities
may compound the problem. Though Schwarzenegger didn't cut
Medi-Cal, the state's Medicaid program, as much as expected
in his latest budget, advocates worry that his proposal for
caps on state spending will eventually compel eligibility
reductions that increase the number of uninsured.
California could make different choices that
direct more resources to health coverage. But ultimately even
a state as wealthy as California can't permanently reverse
the trends reducing access without national action. The problem
is that national action may not come until more states create
momentum by acting first. It may sound paradoxical, but as
California struggles with its healthcare crisis, the best
way for the state to attract national help is to move forward
without it.
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