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You haven't heard much talk in Washington about a big fix for health care since Hillary Clinton's effort crashed in 1994 and almost took her husband's presidency with it. But the problem of rising costs and diminishing coverage hasn't gone away; it has got worse, to the point where some states now devote more of their budget to Medicaid than to education. Health fears always rank near the top of voter concerns.

So reform is back in a big way--only this time, the push is coming from the states. Massachusetts passed a program last year requiring nearly all its citizens to carry health coverage. Maine and Vermont have moved to guarantee everyone health care as well. And now comes the boldest move, from California, where Republican Governor Arnold Schwarzenegger aims to extend coverage to almost all the 6.5 million uninsured residents of the nation's largest state.

Some elements of Schwarzenegger's plan are strikingly similar to the failed Clinton plan--most notably, a requirement that employers provide coverage for their workers. California's mandatory-coverage rule would apply to businesses with 10 or more employees and give them an option to put 4% of their payroll into a state fund instead.

The parallels have not been lost on Senator Clinton. "There are only a very few ways of getting there," she told TIME in an interview. "That's what everyone is finally recognizing." Schwarzenegger also borrows from the Massachusetts plan a requirement that individuals carry health insurance--the way car owners must have auto insurance--with subsidies for the state's 1.2 million poor. He would pay for part of it with new taxes on hospitals and doctors and offer coverage to illegal immigrants--all controversial ideas.

Since Clinton's plan died, the Federal Government has attacked health care only at the margins--by covering more children, for instance, and narrowing the parameters by which insurance companies can deny coverage. Oregon Senator Ron Wyden, a Democrat, proposed a universal-health-care bill in December, but it has got virtually no help from the Democratic leadership. In the last election, House Democrats made only narrow promises on health-care coverage in their "Six for '06" agenda, including Medicare prescription-drug reform and the funding of stem-cell research.

But some believe the political climate around the issue is changing as the problem gets worse. "It is harder for anyone to claim that the market will correct itself if only government would stay away," says Ira Magaziner, the policy guru behind the Clinton plan.

Clinton says lawmakers will be watching closely to see how California and other states fare in trying to solve a national problem that Washington has abandoned. "We'll learn a lot about what works and doesn't work," she says. "We're certainly going to see the political hurdles … There isn't anybody in the country who knows more than I do how difficult this is."

At least one Republican Governor will soon find out.

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By Karen Tumulty

STATES' HEALTH INSURANCE PLANS WON'T CURB COSTS

New plans in Massachusetts and California to reduce the cost of health insurance will do the opposite ("States take on national health insurance crisis," Our view, Health care reform debate, Tuesday).

When politicians "mandate" something, they cannot resist meddling with and overregulating the laws we will be forced to obey. Requiring all insurance policies in California to pay for "wellness" care, such as everyone's gym memberships, will not reduce insurance premiums. A new tax on physicians and hospitals will not curb the cost of health care.

These proposals are just another case of the growth of government making things worse in the name of making them better.

Richard E. Ralston, executive director, Americans for Free Choice in Medicine, Newport Beach, Calif.

Taxpayers will foot bill

USA TODAY's article "Schwarzenegger proposes health plan" outlines another liberal, socialist program in California that requires those who work and pay taxes, the middle class, to support those who don't (News, Jan. 9).

Ostensibly, the program will operate with, as USA TODAY says, "the state's doctors, hospitals, insurers, taxpayers and employers all helping pay for it" -- as though each group had respective pockets. No doubt, costs will be passed down to the only group shouldering the burden -- taxpayers.

The article observes that the plan may have "ripple effects" across the nation. In other words, California Gov. Arnold Schwarzenegger, seen as a charismatic, hard-working moderate, is the one pushing just another national social boondoggle. This way, it doesn't have to be proposed by House Speaker Nancy Pelosi, D-Calif., or Senate Majority Leader Harry Reid, D-Nev., viewed by many as "tax-and-spend liberals."

Schwarzenegger said, "We can make health care more affordable, accessible and equitable for everyone." Really? Does that include all illegal aliens?

He also says people may be rewarded for living healthy lifestyles. Why isn't this already the case? Why must they accept reforms before they see these rewards?

Yet another twist: Insurers won't be able to turn away applicants because of health problems. Apparently, people who have made poor choices that resulted in chronic, long-term diseases would be supported by more responsible insured people.

Great. Just what we need: another program where those who work, pay taxes and take care of themselves pay for those who don't.

Timothy Brown

Cincinnati

(c) USA TODAY, 2007

PLAN FOR COVERING THE UNINSURED BANKS ON FEDERAL DOLLARS

A broad-based coalition of healthcare groups today unveiled a proposal for covering the nation's 47 million uninsured, largely through increased government funding. The two-phased proposal, which is being shopped around to lawmakers, would aim its first effort at 9 million uninsured children. It would expand the State Children's Health Insurance Program to all eligible children and provide tax credits for families below 300 percent of the poverty line to cover their children through private insurance. The first phase would cost about $45 billion over five years, according to Families USA President Ron Pollack, a coalition member. The coalition did not agree how the proposal would be paid for, other than that it should be funded by the federal government. "This is part of their responsibility, from our point of view," said Federation of American Hospitals President Charles Kahn, another coalition member. The coalition consulted with state organizations — the National Governors Association, the National Association of Counties and the National Conference of State Legislatures — but it did not seek administration or congressional advice. Pollack said the state organizations were adamant about opposing any new healthcare authorizations not backed up with federal funding. The coalition plans to use upcoming SCHIP reauthorization, which lawmakers want to pass by May, as a vehicle for its "Kids First" proposal. The $45 billion needed to pay for the children's piece would be on top of the $10 billion to $15 billion lawmakers estimate will be needed to keep the SCHIP program functioning without expansion.

The second phase of the coalition's plan, for which there is no timetable or cost estimate, would give states' flexibility to expand Medicaid to cover adults with incomes below the federal poverty level. For adults with incomes between 100 percent and 300 percent of the poverty level, tax credits would help them cover themselves through private insurance. Coalition members sidestepped funding questions in a Congress governed by tight budgets and pay/go rules. "The cost of not doing anything is even more dramatic," said United Health Foundation Senior Vice President Reed Tucker, adding that the group "has the political muscle" to advocate its position. "We are committed, through our presence here today, that all of us are sticking together," he added.

The coalition includes organizations from across the political spectrum, including the U.S. Chamber of Commerce, America's Health Insurance Plans, the American Medical Association, the American Hospital Association, Catholic Health Association, AARP, and the United Health Foundation. Several healthcare providers such as Blue Cross Blue Shield, Kaiser Permanente and Pfizer also are members. Staffers for lawmakers who will be involved in the issue could not comment at presstime. House Energy and Commerce Health Subcommittee Chairman Frank Pallone, D-N.J., said last week his priority was expanding SCHIP to all who are eligible.

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By Fawn Johnson

ANALYSIS QUESTIONS INFLEXIBILITY OF CONTRACTS

Districts could save billions if freed from terms, author says

Many school districts could lavish a fifth or more of their current budgets on measures to raise student achievement if they axed spending on teachers' contract provisions that do little good in that area, argues a report unveiled last week by the think tank Education Sector.

Among the provisions that researcher Marguerite Roza contends "have a weak or inconsistent relationship with student learning" are such common arrangements as teacher salary increases based on years of experience and advanced degrees, days set aside for professional development, extra teachers' aides, class-size limits, and generous sick leave, health benefits, and pensions.

If the deals for teachers did not include any of those perks, Ms. Roza of the University of Washington's Center on Reinventing Public Schools calculated, the nation's public schools would have about an extra $77 billion a year to spend.

The researcher said she got interested in the topic working with school district officials trying to figure out how to use their money more strategically.

"They'd often point to the labor contract as a barrier because they had kind of written it off" as money already spent, she said in an interview. It's not a question of saving the money, Ms. Roza explained, but of spending it "differently with greater effect."

For example, raises for job longevity and generous health insurance could be traded in for better salaries to attract high-quality beginners, the report says. Or smaller class sizes and some classroom aides might be sacrificed to hire teachers for after-school tutoring.

Many schools, particularly those serving poor children, likely require significantly more money to improve achievement, and in many cases, it would have to come mostly from the existing budget, Ms. Roza added.

Others are also calling for new compensation and accountability systems for teachers. The New Commission on the Skills of the American Workforce last month laid out a plan that would radically overhaul pay, pensions, and health benefits for teachers, among other changes. (See Education Week, Dec. 20, 2006.)

Benefit Reductions

In Ms. Roza's view, by far the largest chunk of questionable spending in teachers' contracts is salary increases for years of experience, which she estimates at an average of slightly more than 10 percent of district budgets. The Education Sector report points to research showing that teachers typically improve through the first five years of their careers, plateau, and then get worse as they approach retirement, even though some newbies are better than veterans. Salary schedules might be restructured accordingly, the study suggests, with higher starting salaries and raises for effectiveness rather than years on the job.

Other contract provisions award teachers better benefits than private-sector professionals', including more sick- and personal-leave days, better health insurance, and more generous pensions, according to the report. The leave policies serve as an incentive for teachers to take days off, and the pensions have left many districts with a disproportionate number of senior teachers, Ms. Roza said.

These negative effects, the report says, could be countered by cutting the number of sick days to about three per school year--comparable to what other professionals get--and by reducing retirement benefits but making them more portable so as to attract talented, newer teachers.

Ms. Roza, who is also a nonresident senior fellow at the Washington-based Education Sector, took pains to avoid being labeled anti-teacher, pointing out that contract provisions are the work of administrators as well as teachers' unions. Also, she argued that many teachers would benefit from changes that enhance the quality of schools.

'Misguided' Analysis?

But leaders of the nation's two largest teachers' unions said they saw virtually nothing in the report to benefit teachers or students.

Antonia Cortese, the executive vice president of the American Federation of Teachers, blasted the study for what she says is shoddy research and "misguided" analysis. "Schools can only be improved if educators, district officials, and politicians work together to develop real solutions instead of making unions scapegoats," she said in a statement.

Reg Weaver, the president of the National Education Association, said in a statement: "It saddens me that someone would suggest that increasing class sizes, firing education-support professionals to raise starting teacher salaries, reducing salaries significantly for experienced teachers, and slashing educators' health benefits and pensions will improve the public education system."

Others saw the proposal as, at best, pie in the sky.

"Cost structures in any public or private sector [institution] have not developed historically as a matter of pure efficiency or effectiveness," Gary Sykes, a professor of educational administration and teacher education at Michigan State University in East Lansing, wrote in an e-mail. "Rather, they reflect a wide range of historical developments that have gradually become institutionalized in particular arrangements. To undo this in accordance with some 'reform' idea is highly unlikely," he said, because of the interests and routines that have formed the arrangements.

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By Bess Keller

EARLY EDUCATION, CHILD HEALTH CARE GET PUSH IN WASHINGTON STATE

Deeming education her top priority, Gov. Christine Gregoire pledged in her Jan. 9 State of the State address to improve opportunities for the youngest children in Washington state by spending more money on early education and health care.

Gov. Gregoire, a Democrat elected in 2004, proposed adding more early-learning slots in prekindergarten programs and phasing in voluntary full-day kindergarten, starting with schools with the highest poverty levels. In addition, she wants to lower class sizes in kindergarten through third grade.

The governor also called for a voluntary rating system for child-care facilities. "We rate restaurants, hotels, and music, don't you think we should rate the places we en-trust with our children?" she said.

Although she said Washington is marching toward its goal of ensuring that all children have access to health care by 2010, Gov. Gregoire said more needs to be done. She wants to provide health insurance to 32,000 children out of the approximately 70,000 who don't now have coverage, and raise the reimbursement rate to pediatricians so families in a state-funded program can have easier access to doctors. She also wants to spend $26 million to provide vaccines for more children.

Improving mathematics and science in the state's schools also was a theme of Gov. Gregoire's speech. She wants to require smaller classes in those subjects, at a 25-to-1 student-to-teacher ratio, and to tie math and science education to international standards. She wants to recruit 750 new math and science teachers, including some from the private sector, by offering college scholarships and loan forgiveness.

"This nation met the challenge of President Kennedy in the 1960s to be the first to put a man on the moon," she said. "Our modern-day moon challenge is to meet the math and science crisis facing our state and nation."

In the area of higher education, Gov. Gregoire proposed making room for an additional 8,300 students in state institutions of higher education, including 3,300 slots in the high-demand fields of computer science, health, engineering, and construction. She also called for a tuition cap to rein in the rising cost of a higher education, and a tuition freeze at the state's community and technical colleges.

Gov. Christine Gregoire

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By Michelle McNeil

STATE PLANS MISS THE POINT

California Gov. Arnold Schwarzenegger has proposed a $12 billion health care package that he says should be the model for the rest of the country. Forcing people to buy health insurance will not solve the problem of the uninsured, make America healthier or decrease the amount of money we spend on health care. Such schemes will increase taxes, kill jobs and destroy private health care markets. They are also the next logical step on the path to single-payer health care.

"Everyone in California must have health insurance," Schwarzenegger declared. This is already true for automobile insurance, yet up to 25% of the state's residents leave home without it.

In Massachusetts, only four in 10 of those eligible for the totally free Commonwealth Care have signed up. Premiums for the subsidized plans are set as high as 6% of the insured's income, prompting talk of not enforcing the individual mandate.

Politicians justify these plans by alleging unfair cost shifts from the uninsured to the insured. Yet these plans rely on massive cost shifts. In Massachusetts, federal taxpayer money will be shifted to providers. In California, the governor calls for an increase in rates for providers from government insurance and then taxes some of this back with new taxes on physicians and hospitals. This is simply a way to increase taxes on private plans and send the money to government plans.

Schemes based on individual mandates will require new and extreme regulation of the private insurance market. Under California's plan, insurers won't be able to turn down anyone based on health status or age, a policy that causes premiums to skyrocket. In 1993, premiums jumped 500% when New Jersey passed a similar regulation.

Americans are highly conflicted when it comes to health care. We think the quality of the system is poor, yet we praise our individual care. We support universal coverage, but not if it entails any restrictions or costs more. Arnold and company better hope that these sentiments don't apply to California, because the move to universal coverage not only costs more, but will only come from mandates and will arrive with plenty of restrictions.

Sally C. Pipes is president and CEO of the Pacific Research Institute, a health policy think tank.

(c) USA TODAY, 2007

STATES TAKE ON NATIONAL HEALTH INSURANCE CRISIS

The list of what's wrong with American health care is sickeningly long and increasingly familiar to millions.

•One in seven Americans, lacking insurance, foregoes needed care or receives treatment that's inadequate and expensive at overcrowded emergency rooms. Most of the cost is passed on to others.

•Those lucky enough to have insurance have seen their premiums double in a decade, while they get less for their money. Co-pays are up, reimbursement rates are down, and some top doctors won't take insurance, making their services available only to wealthy patients.

•Nearly everyone squanders money and time fighting through payment hassles with their insurance companies, and anyone can abruptly be left without insurance at any time, at enormous medical and financial peril.

But now, for the first time since Bill Clinton's health plan collapsed under the weight of its own complexity a dozen years ago, a powerful new move to address those problems appears to be building.

Two Republican governors in Democratic states — California and Massachusetts — have proposed strikingly similar reforms to cover nearly every resident. Roughly, they look like this: Everybody is required to have insurance, much the way car owners in most states are required to have auto insurance now. But they can pick a plan and an insurance carrier that suits them. Prices vary, as does what's provided, but everyone gets at least coverage for some preventive care plus major hospital bills.

Massachusetts' plan, championed by former governor Mitt Romney, who has presidential ambitions, is already in place. In California, where nearly 20% of the population is uninsured, the battle is just beginning. Last week, Gov. Arnold Schwarzenegger proposed covering all 6.5 million of them, including 1 million illegal immigrants. Those who have insurance also would benefit, because they now pay a hidden tax estimated at $1,186 per family to cover unpaid medical bills of the uninsured, according to the New America Foundation, a health policy think tank.

As in Massachusetts, the plan would require most employers to provide coverage or pay additional taxes, which would be used to subsidize their employees and others needing insurance. It also makes tough demands on doctors, hospitals, insurers, taxpayers and employers. Schwarzenegger argues, logically, that cost savings can be achieved only when everyone has coverage so that the healthy join insurance pools along with the chronically ill. Nearly 3 million Californians whose jobs provide coverage turn it down because they think they don't need it.

There's "something for everyone to hate" about both states' plans, as many commentators have noted. Those on the left argue that they don't guarantee affordable premiums and could cause employers to drop coverage; business groups say the plans amount to a new tax on employers that could kill off jobs. But there's no such thing as a health plan that has no downside, which is why reforms are so easily demonized and killed by interests that benefit from the inefficiencies of the current system.

There's a lot to like in the two states' plans:

•Unlike European-style plans, they preserve private insurance, and therefore choice and innovation, with government oversight.

•They spread the cost burden fairly and more efficiently. Everyone is covered; everyone must contribute. Government subsidizes the poor, which is more cost-effective than the way their care is handled now.

How well the plans will work — and whether California's will even be passed — remains to be seen. But the good news is that after a decade of dormancy, attempts are finally being made to fix a system that tens of millions of people recognize is broken.

A national solution would be preferable, but having states serve as laboratories for experiments will let us see which ideas work and which ones should be abandoned.

Perhaps Washington will take notice and at long last act.

(c) USA TODAY, 2007