A dozen governors this year - both Democrats and Republicans - are trying to use state governments to deliver health insurance to people who have jobs but still can't afford health care.
Their approaches vary widely. Five Democrats are championing measures that would guarantee children access to health care. Other proposals would set up a network of cheap clinical services in West Virginia, require everyone to obtain insurance in Massachusetts and offer tax breaks to small businesses for health insurance costs in Kentucky and Arizona.
Of the nearly 46 million uninsured Americans, 81 percent live in families in which someone works. But fewer employers are offering insurance as soaring health care costs make plans more and more expensive.
Wisconsin Gov. Jim Doyle (D) used his State of the State address to blast Congress and the president for leaving so many uninsured.
"No state can solve the national health care crisis by itself. … But Washington's failure can't be ours. We must do what we can to make health care more affordable for average Wisconsin families," Doyle said. He urged Wisconsin lawmakers to provide health insurance for all of the state's children this year.
There are several likely reasons for the sudden rush of proposals to cover uninsured workers and their families.
First, the financial picture for states is looking better than in any of the past five years. In Hawaii, which is flush with a projected $574 million surplus, Gov. Linda Lingle (R) asked lawmakers to extend Medicaid-related health benefits to another 29,000 Hawaiians in the next six years.
But many of the governors' proposals would pay for themselves - with premiums or savings elsewhere in the budget. Still, fatter bank accounts make the expansions easier to sell.
Second, this is an election year. Providing health care coverage for children seems to be a particularly popular topic for Democrats this year.
Doyle of Wisconsin and Gov. Rod Blagojevich of Illinois, both Democrats who could face tough re-election bids this November, called for insuring all of their states' children by the end of the year. Blagojevich already received the go-ahead from Illinois lawmakers, but Doyle's version faces a less certain future.
New Mexico Gov. Bill Richardson and Kansas Gov. Kathleen Sebelius both are promoting the goal of insuring all children ages 5 and younger. Washington Gov. Christine Gregoire (D) is pushing to cover all of the state's children by 2010.
Democrats signaled the importance they placed on the insurance issue when the Democratic Governors Association unveiled a package of federal proposals Jan. 24 designed to increase America's economic competitiveness.
Speaking at the Washington, D.C., press conference, Pennsylvania Gov. Ed Rendell (D) said Democratic governors were turning to Congress for an additional $12 billion for the State Children's Health Insurance Program, with the ultimate goal of providing health insurance to every child in the country.
Congress is on the verge of approving legislation to hold down the price of Medicaid, the joint state-federal program that insures poor families, the disabled and poor seniors.
The National Governors Association championed many cost-cutting ideas for Medicaid. But many of the new initiatives outlined by governors to help the uninsured would help people not covered by Medicaid.
In Illinois, Blagojevich is to roll out his plan this summer. The cost for families to buy into the All Kids program will depend on their income, but it won't depend on the medical condition of the covered children. The administration plans to finance the programs' projected initial cost of $45 million a year by making the state's core Medicaid program more cost-efficient.
Meanwhile, Massachusetts Gov. Mitt Romney (R) is negotiating with the Democrat-controlled Legislature on a plan for state-backed insurance for Bay State residents. Although the details are still being hammered out, the plan could require individuals to obtain health insurance and tax companies that don't offer health benefits to pay for the state-subsidized insurance.
In Tennessee, Gov. Phil Bredesen (D) is working out a proposal in which the state, the federal government, private industry and employees all would chip in to fund a low-cost insurance program for those not covered by TennCare, the state's Medicaid program that recently cut more than 190,000 people from its rolls.
And, during his State of the State address, West Virginia Gov. Joe Manchin (D) suggested a clinic-based system that would let patients access basic services, such as checkups, X-rays and sick visits, for a small monthly fee.
Manchin's initiative is focused on preventive care and would not include hospital visits or treatment by specialists. A more comprehensive version would be available to those who could afford it, Manchin explained.
"While it is not the Cadillac of health care programs, it is a form of meaningful, and portable, insurance that will provide the crucial primary and preventative services individuals and families need to meet the majority of their health care concerns," he told lawmakers.
Most of this year's proposals aren't as ambitious as Maine's Dirigo program, a wide-reaching initiative launched in 2005 that is designed to hold down health care costs and use those savings to provide cheaper health insurance for Maine residents.
Some 8,700 Mainers signed up for coverage under Dirigo by November, the 11 th month it was up and running. But Dirigo also faces hurdles, including legal challenges to the fees it imposes on insurers to pay for the program.
Alice Barton, the director of State Coverage Initiatives , said what state governments can offer the uninsured depends a lot on from where they're starting.
States such as Massachusetts and Illinois can offer more ambitious proposals, because they already have boosted enrollment of low-income families and taken other measures, such as offering special insurance for high-risk patients, that make health coverage more affordable. But states such as West Virginia, which doesn't have the funds to support those broader goals, must use more modest approaches, she said.
Barton, whose group released a report last week on state health insurance efforts last year, said most state efforts likely will continue to help small businesses afford the cost of health benefits for their employees. New Mexico, Oklahoma and West Virginia rolled out programs last year working with employers to provide health coverage.