Key legislative leaders unveiled a plan yesterday to chip away at the estimated 700,000 Marylanders lacking health insurance - providing some coverage for about 50,000 poor adults and helping health clinics and school health centers expand to treat more of the uninsured.
Although it would be ideal to buy insurance for all who can't afford it, "we're not going to see that kind of money soon," said Montgomery County Del. John Adams Hurson, chairman of the House Health and Government Operations Committee. "While we're waiting for nirvana to arrive, we've got to find a way to give care to more people."
The expansion would come at a time when most states, pressed for cash, are cutting back their Medicaid programs.
Joining Hurson in sponsoring the package are the leaders of the two Senate committees that handle health legislation, Baltimore County Sen. Paula C. Hollinger, of the Education, Health and Environmental Affairs Committee, and Charles County Sen. Thomas M. "Mac" Middleton, of the Finance Committee.
That much leadership muscle gives the package a lot of momentum, and the three Democrats said they saw a growing consensus among lawmakers that something must be done in this session to expand coverage.
With support coalescing around the more limited changes, prospects become less certain for a more ambitious "health care for all" package being pushed by a group called Maryland Citizens Health Initiative. That plan would insure virtually everyone in the state by expanding Medicaid, subsidizing coverage for moderate-income adults and requiring higher-income Marylanders to buy their own coverage. It would finance the coverage in part by taxing employers that don't offer coverage.
Vincent DeMarco, president of the health initiative group, said yesterday he was "thrilled" by the plan offered by committee chairs. "We're going to have significant progress this year on health care," he said. He noted that some elements of his group's plan, including an increase in tobacco taxes to increase payments to doctors who treat the poor, had been adopted by the legislative leaders.
Middleton said his committee would review all plans for expanding coverage, potentially picking pieces from each to support. Hurson said he, too, was looking at other bills to expand coverage, including one by his vice chairman, Baltimore Del. Peter A. Hammen, imposing a state tax penalty on higher-income people who don't buy their own health coverage.
State health secretary Nelson J. Sabatini, who has talked about offering his own sweeping reform plan when the state gets beyond its budget crisis, said that at this point, the Ehrlich administration agrees with the general approach of the legislative leaders. "You've got to solve it on an incremental basis," Sabatini said.
Sabatini said he has not had a chance to study the details of the legislative proposal but expected "the problematic part will be the HMO tax."
The plan proposes to extend to HMOs a 2 percent tax on premiums already being paid by all other health insurers in the state. An HMO tax passed the legislature last year, but businesses complained it would drive up the cost of insurance, and Gov. Robert L. Ehrlich Jr. vetoed the tax bill that contained it.
Hurson said he hoped to convince the governor to support the legislative plan.
The HMO tax would raise about $50 million - matching the cost of expanding Medicaid to cover an estimated 54,000 adults with incomes below the federal poverty level ($15,250 for a three-person household). Currently, adults must be well below the poverty line - at 30 to 40 percent of federal guidelines - to qualify for Medicaid coverage.
The expansion would not cover hospital care, which is already provided by the state's system of passing along the cost of the uninsured. Providing the full Medicaid package for the 54,000 adults would cost about $150 million, according to preliminary estimates from committee staff.
Still, any expansion of Medicaid coverage these days is rare.
As states cope with tight budgets, 49 have cut Medicaid - through a combination of reducing benefits, tightening eligibility, adding co-payments and lowering reimbursements to doctors and hospitals - said Victoria Wachino, associate director of the Kaiser Commission on Medicaid and the Uninsured in Washington. Only two have had recent expansions, Wachino said, and both those made cuts elsewhere in the program to finance the added coverage.
Donna Cohen Ross, outreach director for the Center on Budget and Policy Priorities in Washington, said that according to a survey by her organization last spring, 16 states provided Medicaid coverage to parents up to the federal poverty level. Utah, she said, offers a similar program to that proposed for Maryland - primary care coverage for adults, whether or not they are parents - but needed to get a waiver from federal officials since the plan doesn't follow normal Medicaid rules.
States have broad leeway in how to structure Medicaid programs within the federal guidelines, which direct most coverage to children in low- and moderate-income families, the disabled, and elderly in nursing homes. The federal government pays about half the cost of Medicaid programs.
In addition to the Medicaid expansion, the leadership proposal seeks to shore up the safety net for the uninsured by helping community clinics expand.
Miguel McInnis, chief executive officer of the Mid-Atlantic Association of Community Health Centers, said there are about a dozen nonprofits in the state providing care at 57 sites to about 130,000 people. Of those, he said, about 30 percent are uninsured. A combination of state and federal aid for expansion could allow the clinics to more than double the number of patients treated, he said.
Hollinger, who said she worked five years as a school nurse, said she welcomed the plan to support school-based clinics, which provide a variety of pediatric services and which she described as "the friendliest place in the community for people to come."