For almost a dozen years, conventional wisdom has dictated that far-reaching, national health care reform wasn't possible in this country. But political winds are blowing in a strong new direction.
Now, states are seizing the initiative on this issue, challenging persistent policy deadlock in Washington. Business groups are standing with labor unions and consumer activists, calling for reform. Even the insurance industry has advanced a proposal for universal coverage.
As a new wave of reform initiatives surges across the nation, Congress is showing interest in supporting state innovations and is likely to begin a renewed debate over which direction national reforms should take.
Republicans are stepping forward with bold plans - a sign that previous partisan divides over health reform are weakening. This month, California Gov. Arnold Schwarzenegger, a Republican, made an enormous splash when he advanced a plan to cover 6.5 million uninsured residents of his state.
Another leading Republican, former Massachusetts Gov. Mitt Romney, makes no secret of plans to promote the universal health care initiative his state enacted last year on the campaign trail if, as expected, he runs for president. That will pressure other candidates to respond - especially Democrats, who have traditionally made health care one of their priorities.
"With two high-profile Republicans backing major reform, it really forces the Democratic candidates to match them in this area," said Robert J. Blendon, professor of health policy at the Harvard School of Public Health. "And it's really going to escalate the issue nationally in the primaries and in the presidential election."
Last week, organizations that squared off angrily over health care in the 1990s - including Families USA, the U.S. Chamber of Commerce and America's Health Insurance Plans - stood together in Washington, D.C., announcing a commitment to what they agree are much-needed expansions of medical coverage for children and low-income adults.
"With such divergent ideologies, it is unprecedented for these groups to have a joint agreement," said Scott P. Serota, president of the Blue Cross and Blue Shield Association.
Democrats are hardly staying on the sidelines. In recent days, the governors of Pennsylvania and New York have pledged to expand health care coverage in their states.
Driving the activity is a deepening sense of frustration over escalating medical costs and growing numbers of people without medical coverage, the underpinnings of the nation's accelerating health care crisis. While these long-term trends aren't new, their impact on businesses' bottom lines, consumers' pocketbooks and medical providers' practices has worsened significantly, experts said.
The result is what former Speaker of the House Newt Gingrich - a Republican who helped sideline national health reform a dozen years ago during Bill Clinton's presidency - calls an "emerging consensus that we have to find some way to cover everybody."
Whether the business community, which tends to dislike mandates, will buy into proposals that would expand its financial obligations for health insurance is an open question.
"I have yet to be convinced," said Drew E. Altman, president of the Kaiser Family Foundation. While many large companies think that health reform might help control benefit expenses, many small firms argue that they lack the wherewithal to pay.
And there's deep concern over accelerating medical costs, which will inflate the future price tag for proposals to expand coverage.
With all these obstacles, "I don't see anything major happening before the presidential election" except the likely reauthorization of a children's health program by Congress this year, said Chip Kahn, president of the Federation of American Hospitals, which represents for-profit providers.
Still, others remain optimistic that swelling grass-roots support for reform will help turn the tide. "The opportunity for change is here" because the health care crisis is reaching financially pressed middle-class families who are losing coverage or being asked to pay more for care, said William D. Novelli, chief executive of AARP, the nation's largest senior citizen organization. "When the middle class gets squeezed, something is going to happen."
If current trends continue, 56 million Americans will have no health insurance by 2013, up from 47 million today, according to a new report by AcademyHealth, a policy and research organization. Fewer employers are offering coverage, and those that do are asking workers to shoulder a larger share of the price. And financial strains for millions of families are mounting as medical inflation far outstrips salary increases.
Enter the states, which began to plan new strategies when their revenues started to rebound a few years ago, making new spending possible.
The sheer ambition of the $12 billion plan put forward by Schwarzenegger was breathtaking. Among its most important features is that every business in the state with 10 or more employees would be required to provide medical coverage or pay a fee. Every person in the state would be required to have health insurance, obtaining it from his employer or on his own or from a state pool; low-income families would get assistance.
But the scope of the problem in California is also astounding. About 15 percent of the entire uninsured population of the U.S. lives in the state. Not surprisingly, the governor's plan has been greeted with acclaim and alarm. Noting that Schwarzenegger's plan assumes $5.4 billion from the federal government, "there's a question of whether all that money will come through as hoped," said Marian R. Mulkey, senior program officer at the California HealthCare Foundation.
Judith Graham and Michael Martinez write for the Los Angeles Times.