With a month to go before the opening gavel of the 1992 General Assembly, lawmakers and others are taking the first steps toward a dramatic transformation of Maryland's health-care system.

The longest shot among the horses approaching the gate is also the feistiest: a plan to introduce a "universal access" medical system, similar to the national health plan that Canada adopted 20 years ago, in which the government sets and pays the fees of health-care providers.

Other proposals would make the purchase of health insurance mandatory for either employers or employees.

"If we can find a consensus on which approach to use, we're asking everyone involved, from the president on down, to give us the opportunity to operate a demonstration model in Maryland to prove to the country that that's the way to go," said Delegate Casper R. Taylor Jr., D-Allegany, the sponsor of one of the plans.

Gov. William Donald Schaefer will help focus attention on the issue by sponsoring a two-day health-care meeting, probably in early January, that many are starting to call a "summit," said Paul E. Schurick, the governor's chief of staff.

There is little debate about the current system's flaws: About 570,000 Maryland citizens have no health insurance, and perhaps 1 million more have inadequate coverage, according to various accounts. Nationwide, the latest estimate is that about 32 million people have no insurance.

Most likely to be passed by the General Assembly next year are "small group market reforms," an idea being pushed by the Governor's Commission on Health Care Policy and Financing, better known as the Feinblatt commission.

The commission is calling for guaranteed health coverage for small companies' employees, who have the hardest time finding insurance; rules to prohibit an insurance company from terminating a company's health coverage or greatly increasing rates when one or two people covered by the plan become sick; and lower rates for the highest-risk companies but higher rates for lower-risk groups.

Business and insurance groups are working toward a compromise on small group market reform, representatives of those groups said.

Consensus is less likely on the three major kinds of changes being proposed this month:

* Employer "play-or-pay." Recommended by the Feinblatt commission, this employer tax-incentive system would require companies to offer health benefits to employees or pay a tax to the state. With almost three-fourths of uninsured Marylanders either working or dependents of workers, the plan probably would make insurance available to another 143,000 people, the commission estimated. An additional 76,000 people would receive state-subsidized health benefits paid for by the employer taxes.

Business groups are likely to fight this approach because it continues to place the burden of health-care costs on employers, said Miles Cole of the Maryland Chamber and Economic Growth Associates.

* Individual "play-or-pay." One version of this, sponsored by Mr. Taylor and originally advanced by Carl Sardegna, chairman of Maryland Blue Cross, would give all Marylanders a tax credit to buy health insurance. Employers would have to offer, but not pay for, two levels of health plans, and unemployed people would turn over their tax credits to insurance brokers.

The money to pay for the tax credits would come from one part of the state's Medicaid program for the poor, from the direct savings state and local governments would gain from no longer having to cover their employees and from the abolition of employer tax deductions for health-care payments.

A variation of that plan, proposed by Senate Finance Committee Chairman Thomas P. O'Reilly, D-Prince George's, would require all employees to buy insurance or, if they chose to remain uninsured, to pay into a statewide fund, based on their income. Insurers and health maintenance organizations would be assessed to cover the costs of people they refused to insure, as well as the individuals who couldn't or wouldn't buy insurance.

* Universal health insurance. Proposed by Sen. Paula C. Hollinger, D-Baltimore County, this plan most closely resembles the Canadian system. A board of governors would set the prices for all outpatient services that aren't regulated, craft a benefits package and hire a single company to administer a universal health insurance fund.

The fund would receive all state Medicare and Medicaid payments and all employee health-care payroll deductions, and would pay all health-care providers for services rendered. Like some of the other plans, this one would require waivers from some federal laws, as well as the cooperation of large segments of the health-care industry that stand to lose tremendous amounts of money if it becomes law.

Ms. Hollinger said Maryland already regulates fees and payments for half of its health system: inpatient hospital care. And, in a recent poll, nearly 70 percent of U.S. voters said they would support a Canadian-style universal health-care system.

But even if the idea seems too radical for Maryland's General Assembly, Ms. Hollinger stressed the need to start the debate.

"I think it's real important to get the whole discussion of access off the dime," she said.

Prescriptions for reform

$ Employer Play-or-Pay

Sponsor: Governor's Commission on Health Care Policy and Financing (Feinblatt Commission)

Highlights: Employers (except for one-person companies) required to pay $720 a year per employee for a model health insurance plan, or else pay a $900-a-year tax to the state. Employers who provide benefits to only some employees would receive a discount off their overall tax based on the amount of benefits they provide. Coverage for employees' dependents is not required.

Allies: Insurers, health-care providers whose services are covered by a model benefits package, and, depending on the model plan, consumer and labor groups.

Enemies: Employers and providers whose services are not covered by the model benefits package.

Individual Play-or-Play

Taylor Variation

Sponsor: Delegate Casper R. Taylor Jr., D-Allegany (based on an idea from Blue Cross Chairman Carl Sardegna).

Highlights: Employer contributions to health coverage no longer are tax exempt, but all Marylanders receive a tax credit to buy a qualified health insurance plan. The size of the credit depends upon family income. Unemployed and other low-income

individuals turn over their credit to licensed brokers, who "pool" such clients and buy coverage for them.

Funding would come from part of the state Medicaid budget, the direct savings that state and local governments would realize, and higher individual and corporate taxes that could result.

Allies: Employers, insurers and providers whose services are covered in a basic health plan.

Enemies: Consumer and labor groups and providers whose services aren't covered.

O'Reilly Variation

Sponsor: Sen. Thomas P. O'Reilly, D-Prince George's.

Highlights: Only employed or self-employed individuals are required to buy insurance. Insurers administer, but not necessarily pay for, coverage for all citizens. The companies are reimbursed for the administrative and health-care costs of their clients who can't pay for insurance, including Medicaid patients (an exemption from federal law would be necessary). Those extra costs, as well as the cost of caring for the remaining uninsured population, would be funded by federal and state Medicaid payments, and by general assessments spread among all insurers, who then would pass the costs on in the form of premiums.

Allies: Employers.

Enemies: Consumer and labor groups.

Universal Health Access

Sponsor: Sen. Paula C. Hollinger, D-Baltimore Co.

Highlights: A state board of governors sets prices for all non-hospital and outpatient health care services (inpatient hospital rates continue to be set by the Health Services Cost Review Commission). The board also approves a package of benefits to be provided, and hires a company to administer claims and pay non-hospital providers.

The plan would be financed by Medicaid and some Medicare funds, and by an employee payroll deduction to be determined by the board. Also, long-term care and catastrophic care accounts would be established with a further payroll deduction.

Allies: Consumer groups.

Enemies: Insurers and health-care providers.