The Maryland House of Delegates approved a plan yesterday to extend medical coverage to more than 100,000 residents, but the measure faces strong opposition in the Senate, where legislative leaders oppose funding health care through a $1 increase in the tobacco tax.
The House vote of 102-37, largely along party lines in the Democratic-controlled chamber, could mark an end to months of work on the bill, which backers said is a first step toward universal coverage. Nearly 800,000 Marylanders lack health insurance, or 14 percent of the population.
Senate President Thomas V. Mike Miller has said repeatedly that his chamber would not approve a tobacco tax increase to fund health care, and that the state cannot afford to expand social programs in the face of a $1.3 budget shortfall next year. House leaders want to double the tax to $2 for a pack of cigarettes; their plan would cost about $200 million in state funds a year.
"It's not fiscally responsible," Miller said. "It's like building an addition on your house when you can't even pay your mortgage."
House Speaker Michael E. Busch, an outspoken proponent of the measure, said he believes it has the support needed to pass the Senate, where Miller can determine what bills are brought up for a vote. Busch also warned that if the current growth rate in the number of uninsured continues, another 50,000 people could go without insurance next year.
"We need to take immediate action," Busch said at a press conference, where he indicated willingness to compromise. "We're open to everything the Senate determines they have the political will to debate."
Legislative leaders and Gov. Martin O'Malley early this year identified health care, and how to get more uninsured residents coverage, as one of the top issues before the General Assembly. The issue is being debated nationally. The Iowa legislature recently passed a $1-per-pack increase for cigarettes to fund health programs, and last year eight states upped the tax.
More ambitious programs have been undertaken in Massachusetts, which enacted groundbreaking legislation to cover most of its uninsured last year. California Gov. Arnold Schwarzenegger also has unveiled a proposal for near-universal health care.
But in Maryland, the issue has been caught up in the debate over when legislators should begin to address looming budget problems. O'Malley says the budget deficit could dictate how quickly the state can act to expand access to health care, and he opposes relying on the tobacco tax because it's a declining revenue source.
"While the governor supports the goals of the legislation, the question is how fast can we move forward," said spokesman Rick Abbruzzese.
The House bill's main component is to expand Medicaid, the government health insurance program for the poor. The number of people who eventually get insurance through the bill could rise above the current estimate through higher enrollment rates.
The governor has proposed a more modest expansion of Medicaid that might have a better chance at passage this year if the cross-chamber impasse over the House bill isn't broken.
O'Malley's bill would make more children eligible for Medicaid and cost roughly $6 million in the first year. The bill also would create an exchange, similar to one in Massachusetts, that would pool small employers and perhaps individuals to get access to a broad range of affordable policies.
Sen. Thomas M. Middleton, chairman of the Finance Committee and a Charles County Democrat, said his panel is set to review the House bill and the governor's bill next week.
The House bill would triple the maximum allowable income for Medicaid coverage for adults to about $12,000 a year for an individual. And it would extend Medicaid to children from families with incomes up to four times the federal poverty level, or $82,800 for families of four, while allowing families above that level to buy into Medicaid at cost.
The bill had been trimmed in committee, where delegates dropped plans to give small businesses subsidies to provide insurance to workers, and to require that higher-income residents buy insurance or pay a fee. But they retained another provision that would require insurers to allow adults up to age 25 to stay on their parents' plan.
Republicans, including Del. Steve Schuh of Anne Arundel County, took issue with the proposed higher income levels, saying that Medicaid is intended to be a safety net for the poorest residents. Republicans also opposed the measure's reliance on the tobacco tax.
"My main problem with the bill is that it is relying once again on a tax increase to solve a problem," said Del. Christopher B. Shank, the House minority whip from Western Maryland. "This is the time that we should be curtailing spending rather than approving a massive new entitlement program."
The bill's chief author, Del. Peter A. Hammen, who chairs the House Health and Government Operations Committee, defended the extent of the Medicaid expansion. He explained that those in the higher income brackets pay on a sliding scale. He also pointed out that all residents end up paying for the uninsured through higher insurance rates.
Under Maryland's system, hospitals are reimbursed for treating the uninsured -- an estimated $800 million a year -- through higher rates charged at all hospitals. That pushes insurance rates higher, adding an estimated $1,000 to the annual premium of the average family plan.
"This is the foundation from which to build," said Hammen, a Baltimore Democrat. "Why wait? Let's act now. This is a problem that's not going to get better. It's only going to get worse."
Sun reporter Andrew A. Green contributed to this article.