Universal coverage: The next frontier?

Experts say not so fast as states face economic, federal barriers to next stage of health care expansion

The panel will face a challenge that health advocates and labor officials say demands a national solution: How to provide health care to the 800,000 uninsured Marylanders at a time when costs are rising, the economy has taken a downturn and states are facing a number of hurdles from the federal government.

‘‘There are some problems that are so big and so great that we have to look at it from a national perspective,” said Patrick Moran, director of AFSCME Maryland, which represents 30,000 state employees.

Last fall, while wrangling with a $1.5 billion budget deficit, state legislators approved expanding Medicaid to parents of children enrolled in the Maryland Children’s Health Program and uninsured adults with incomes at 116 percent of the federal poverty guidelines, or $11,844. The expansion package also included subsidies for businesses with two to nine employees whose average wages are below $50,000 a year.

Advocates called it a first step that would insure about 60,000 childless adults and 40,000 more through an initiative for small businesses.

‘‘We’re going to be looking for solutions on health care for many years,” Gov. Martin O’Malley said Wednesday. ‘‘We hope with the new president that we’ll have [a] federal government that’s committed to the goal of universal coverage too. I think that’s our best hope on the horizon.”

Health advocates in the General Assembly are focused on building on what has been accomplished in the first two years of the O’Malley administration, said House Health and Government Operations Chairman Peter A. Hammen.

Lawmakers find themselves swimming against the current.

‘‘Four years ago we had 600,000 uninsured, today we have 800,000 uninsured,” said Hammen (D-Dist. 46) of Baltimore. ‘‘We’ve got to change that direction.”

After the 2007 passage of Medicaid expansion, the legislature took baby steps in 2008. That included a measure to allow some young adults to remain on their parents’ plans until age 25 and a program requiring the state to send application packets to low-income taxpayers whose dependents are eligible for the Maryland Medical Assistance Program or Maryland Children’s Health Program.

While labor unions and advocates are often anxious to take bigger steps toward universal coverage, ‘‘I think the incremental approach really is the best way,” Hammen said. ‘‘No. 1, it is a way to get things done. ... I don’t know whether I can get a ‘Big Kahuna’ bill out of the Senate.”

Meanwhile, the Maryland Health Quality and Cost Council, created by an executive order signed by O’Malley in October 2007, is charged with recommending how to improve health care quality while containing costs. It also will develop plans for caring for patients with chronic disease and sharing health information across health care systems.

‘‘The governor understands that health care reform is more than providing health insurance for people,” Colmers said. ‘‘It’s about reforming the health care system.”

The council will look to bring public and private sectors together, Colmers said.

‘‘It’s not just about providing more coverage, but it is what is the coverage,” he said. ‘‘If it’s more of the same-old-same-old, that’s not a solution.”

Voluntary partnerships between states and private employers, such as Maryland’s new subsidies for small businesses, ‘‘can be very effective,” said Judith Solomon, a senior fellow at the nonpartisan Center on Budget and Policy Priorities in Washington, D.C. ‘‘What’s not possible is employer mandates,” Solomon said. ‘‘Maryland found that out on the decision with the so-called Wal-Mart Law.”

The law called for companies with more than 10,000 employers to spend at least 8 percent of their payroll on employee health care. It would have affected only Wal-Mart.

In January 2007, the 4th Circuit of the U.S. Court of Appeals in Richmond affirmed a U.S. District Court judge’s ruling that the law violated the federal Employee Retirement Income Security Act, which prohibits states from regulating how private employers offer health care to their employees.

‘‘States really have limited ability to affect the employer,” Solomon said.

A 2005-2006 survey by the Maryland Health Care Commission found that 71 percent of Maryland adults under 65 had employer-based coverage.

‘‘Maryland is higher than the U.S. average on employer-based coverage, but we’re still finding some trend over the last decade of trending downward,” said Ben Steffen, director for information and analysis for MHCC.

While states look for creative ways to leverage federal dollars for people without insurance, the federal government ‘‘is being much more restrictive” on how states can spend Medicaid dollars, Colmers said.

Members of the state’s congressional delegation this week called on the federal government agency that administers Medicaid to reapprove funding for Maryland’s Healthy Start program for pregnant women. The Bush administration has proposed new rules that would reduce what it sees as $13 billion in fraudulent or unnecessary Medicaid expenditures, igniting a showdown with a number of states.

‘‘Unfortunately, at the end of this [presidential] administration, we seem to be taking steps away from more coverage,” Colmers said.

There is some good news, Solomon said.

‘‘When we see a more national solution that deals with some of these issues there still will be work for states to do as far as controlling cost and increasing the quality of health care systems,” she said.

With the Health Quality and Cost Council, Maryland is beginning to do that work, she said.

‘‘We’ll continue to try to learn from other states and find new ideas,” O’Malley said. ‘‘If we’re able to restore fiscal responsibility to our state, hopefully we’ll be in a stronger position to be able to implement more of those solutions. Moving forward, all of them taken together will hopefully stabilize what has been an unsustainable rise in the cost of health insurance.”

One place many states have looked is Massachusetts, which last year began requiring residents to purchase health insurance or face a fine. At the same time the state rolled out low-cost insurance plans. About 100,000 previously uninsured people gained coverage in the months leading up to the law taking effect, according to the Henry J. Kaiser Family Foundation.

‘‘Massachusetts was unique,” said Solomon, who advises states considering similar initiatives to ‘‘compare their starting line.”

Massachusetts had a relatively low number of uninsured and was able to draw on federal dollars marked for covering the cost of uncompensated care for the uninsured, she said.

‘‘In other states it’s a variety of things and it’s only gotten worse with the deficit,” Solomon said.

Massachusetts’ program has run into problems and might not be the answer for Maryland, Hammen said.

‘‘How can you require a person to have insurance when they can’t really afford it?” he asked.