A hot topic in state legislatures is universal health coverage. Tired of waiting for the Congress to take action, states are striking out on their own, most notably Massachusetts.

The bill passed last year in Massachusetts was featured at a health forum during the recent annual meeting of the National Conference of State Legislatures.

The Massachusetts model, as described in a recent issue of Governing Magazine, has an individual insurance mandate, requiring all individuals to have insurance or pay fines. Those who can’t afford insurance are given a subsidy. However this year an exemption was granted to about 60,000 individuals (2% of the population) whose income was too high for subsidies but too low to afford health insurance. Individuals choose from a variety of private insurance plans that go beyond the bare bones but have varying levels of coverage. The state was able to negotiate deep discounts from providers, one reason the plan seems to be working fairly well.

Concern about health coverage has risen as fewer employers are offering health insurance at all. Others limit the coverage to the employee but not to dependents. In fact, most of the uninsured are employed. Unable to get insurance on the job, they are also unable to afford individual coverage. Millions more are concerned that they will lose their coverage in the future.

Plans like that in Massachusetts are finding a receptive audience because more citizens are looking for a solution and because they rely on the existing private market rather than starting large government programs.

Other states are experimenting with other approaches.

Illinois, for example, young adults could be covered under their parents’ plans until age 30; eligibility for programs for working parents would be increased to 400% of poverty; and small businesses and employees would be given access to private insurance.

California has a proposal from Governor Schwarzenegger that would pay for the program by imposing fees on health care providers (doctors, hospitals) as well as employers. Further it would require insurance companies to spend 85 percent of their revenues directly on patient care, a way to hold the line on administrative costs.

In New York one approach is an effort to expand home care for seniors and disabled persons. This has real potential to reduce costs and improve patient care at the same time.

Virginia has done a good job getting children enrolled in FAMIS – Family Access to Medical Insurance Security – designed to provide coverage for children whose family income is too high for Medicaid but not enough for private health insurance. In some cases, if the child could be eligible for employer insurance, the state will assist with paying the premiums, another way to work with the private sector.

However, Virginia still has over a million persons without health insurance coverage. We have an opportunity to learn from the experience in other states and begin to play a more constructive role in ensuring coverage for many more Virginians.