The Republican governor of one of the nation's most solidly Democratic states says he can succeed where others have failed: moving toward truly universal access to affordable health insurance.
For Gov. Mitt Romney (R) of Massachusetts, it's a high-stakes gambit to resolve what has become a gut-level concern for millions of families nationwide in an era of rising healthcare costs.
If successful, his effort could not only expand healthcare to more Bay State citizens but point a path for other states, and possibly the federal government. If the plan moves forward but fails to show results, it could deal a setback to the broader Republican Party message that Romney espouses: that incentives and free-market economics, more than government programs, can resolve US healthcare woes.
In the end, the effort here may founder as others have nationwide in recent years. But the urgency of the problem, Romney's credentials as a rising political star, and the desire of Bay State Democrats to expand healthcare all suggest the possibility of at least an interesting experiment.
"No one has come up with an effective and politically feasible solution. It is the ongoing struggle at the state level," says Michael Sparer, a health policy expert at Columbia University in New York. The attraction to be the one to find the answer is undeniable "when you combine that [it is] an area where an ambitious politician might make a real difference with the reality that there is a crisis out there."
Healthcare is a subject that governors can hardly ignore. For the first time, Medicaid expenses this year represented a larger share of state budgets than K-12 education. And the number of uninsured has been rising - 25 percent in Massachusetts since 2000, for example. And with observers speculating that Romney may make a 2008 presidential bid, this is an issue that can build political credentials.
States have diverged in recent years in their approaches to healthcare. In Massachusetts, Romney recently proposed "Commonwealth Care," which would urge insurers to offer less expensive basic healthcare plans. It would also seek to increase Medicaid enrollment, target those fraudulently enrolled in the program, and potentially penalize small companies that deny employees coverage, though it would not compel employers to provide insurance. Romney says no additional state spending should be required.
Nearby Maine is offering residents affordable healthcare using state and federal funds. Like Romney's plan, its Dirigo Health Program is based on a voluntary commitment by the business community. The hope is to cover Maine's estimated 138,000 uninsured by 2009.
As some states seek to expand coverage, others have felt forced to restrict access. Expansion programs were the norm throughout the 1990s, especially for children whose parents were not poor enough to qualify for government-assisted programs. Since then, the number of uninsured children in the country fell from 10 million to 8 million. But rising costs have caused states to cut back on Medicaid.
In 2004, 21 states reduced or restricted residents from accessing Medicaid; 14 plan to do so next year. In Tennessee, the state's TennCare plan, cited as a national model when it began a decade ago, is on the brink of collapse, consuming one-third of the state budget. And in California, a referendum in November rolled back a mandate that required businesses of 200 or more to give workers health insurance.
While the generalization doesn't always hold, Republicans have tended to favor market-based solutions, Democrats have supported a larger government role in providing healthcare.
"The Democrats would rather expand access; the Republicans would prefer to reduce costs," says Howard Berliner, a professor of health policy at the New School for Public Research and a former assistant health commissioner in New Jersey. "Those are two different strategies to get to a somewhat similar goal."
Romney's pledge not to spend extra money as the state seeks to open access to 450,000 to 600,000 uninsured residents has drawn critics - as has his plan to offer a stripped-down policy - a common proposal in many states. Geoffrey Wilkinson, the executive director of the Massachusetts Public Health Association, an advocacy group, worries that those insured under Romney could be denied access to some important procedures or treatments, such as for substance abuse.
"I'm concerned that this basic plan really amounts to second-rate health coverage," he says.
Others say they are relieved to see states trying to tackle an issue that the federal government hasn't addressed. "I think [the Romney proposal] is a laudable effort ... that builds on the momentum of many proposals coming out of Massachusetts," says Barbara Roop, co-chair of the Healthcare for Massachusetts Campaign.
• Material from the Associated Press was used in this report.