A modest approach to health care

Sunday, March 4, 2007 | 7:30 a.m.

Last year Illinois covered all its kids. Proposals on the table this year in Florida and New York would do the same. In California, Republican Gov. Arnold Schwarzenegger is pushing for universal health insurance.

In Nevada, not so much. Assembly Democrats offered their plan last week. Here's the math: The state has about 450,000 residents without health insurance, or roughly 20 percent of the population. The Democratic proposal strives to insure about 12,000 of them.

The modesty of the plan, especially coming from some of the most committed liberals in the Democratic-controlled Assembly, illustrates both the state's financial straitjacket and its still-lively libertarian roots, wherein tax increases are a dead letter.

"We looked at covering all children, but the price tag was huge," said Assemblywoman Sheila Leslie, D-Reno, a caucus leader on health care.

Nevada's fiscal environment and legislative timidity on health care contrast sharply with the mood in much of the country.

A recent ABC News/Kaiser Family Foundation poll found that 56 percent of Americans say they prefer a universal health insurance model to the current system, and Democratic presidential candidates are calling for an overhaul of health care.

States are pushing ahead with incremental reforms that bring the uninsured into the fold, said Laura Tobler, a health care policy analyst for the National Conference of State Legislatures. "That said, there are a lot of people talking about more comprehensive reforms."

"I do think there is momentum," said Dr. Alain Enthoven, a Stanford University health care policy expert. "It's striking that you have (former Massachusetts Gov. Mitt) Romney and Schwarzenegger saying we should have universal insurance, and people aren't saying they're crazy."

The Romney example is compelling. He is a Republican running for president and trying to win over conservatives. But last year he drove legislation in his state requiring every resident to have health insurance and providing financial help to ensure they do so.

Dean Baker, a health care economist at the Center for Economic and Policy Research in Washington, said that a political groundswell is coming from voters who feel deeply insecure about their health care coverage and baffled by a system that is both Byzantine and expensive.

"I think it's clear this is a big issue and it's not going away, and it's not being driven by the politicians."

In recent years, double-digit increases in health care costs have been passed on to insurance companies, who then pass it on to employers who buy health insurance for their workers. Employers are then left with difficult choices: continue the same coverage, but forgo raises; pass on the costs to employees; or, for many small businesses, drop coverage altogether.

Businesses are also driving health care reform. Large employers with significant numbers of retirees, such as automakers, have seen their ledgers lacerated by retiree health care costs. General Motors says those costs add $1,500 to the price of every car.

Policymakers around the country have responded, although often with what could be called a "free-lunch solution." Many argue that by reducing the numbers of uninsured, costs can be contained because there will be fewer uninsured who take their common illnesses to expensive emergency rooms.

Moreover, they say that when patients with chronic diseases, such as diabetes, are treated regularly, the state can avoid the cost of catastrophic care. So, for instance, making sure a diabetic gets daily insulin is cheaper in the long run than treating the blindness or amputation that can follow untreated diabetes.

Baker said the data show expanding health insurance coverage can be cost-effective, but still costs more money than not covering people at all. He also said that covering the uninsured is only half of the puzzle. The other half is meaningful cost containment.

This brings us to Nevada, where meddling in the free market, in the form of taxes and regulation, has long been seen as an impediment to growth and progress.

There are other priorities. A task force has said the state will need at least $3.8 billion in the coming years to meet transportation needs, and Assembly Democrats have staked much of their capital on all-day kindergarten, whose cost isn't yet known but will likely be tens of millions of dollars.

Also, whenever Democrats consider health care reform, the specter of Hillary Clinton is always in the room. Clinton's attempt at universal health care in the 1990s failed badly, and many blame the Republicans' sweeping victory in 1994 on that political debacle.

Only recently have many national Democrats begun to rethink their reflexively incremental approach and consider more ambitious reform.

The Nevada Democrats' plan would cover 5,000 lower-income small-business employees, 1,000 working pregnant women and 6,200 children, all of which would cost roughly $15 million per year.

Assembly Speaker Barbara Buckley, the chief sponsor, conceded that her caucus is boxed in on health care: "We have revenue restrictions, and whenever you're recommending expansion of programs that aren't in the governor's budget, it's hard."

"I wish we were further along, but I only get frustrated when we're standing still," she said.

Comparing Nevada to other states is unfair, she said.

Buckley noted that states that are moving toward universal coverage, such as Massachusetts, Maine and Vermont, have large Medicaid programs and were further along the road to universal coverage when they jumped the final hurdle.

Nevada, by deliberate policy, has among the smallest Medicaid populations in the country per capita, which means the Silver State has large numbers of working poor without coverage.

Buckley is a pragmatist, and a skilled coalition-builder, which is clearly her purpose with this issue. She said that in two years, she will be able to show success in the programs and take a broader approach.

Republican Minority Leader Garn Mabey, a physician, is backing her bill, as is Republican Assemblyman Joe Hardy, another physician.

Bill Erwin, a spokesman for the Alliance for Health Reform , applauded the effort. But he urged Nevada to do more: "You would hope the coalitions being built around this proposal could lead to bigger things later, and having worked on this issue for 20 years, I can say any positive change is wonderful. But clearly if California can do it, then you all can do it, too."