This spring spelled trouble for several pricey plans by governors who had promised universal health care - but efforts, big and small, to insure children are faring better.
"There seems to be a real strong will to expand coverage for children. The only thing that is a roadblock is money," said Kathleen Stoll, director of health policy for Families USA , a Washington, D.C.-based group advocating for public health benefits for children.
One idea popular this spring is hiking cigarette taxes to underwrite broadened health-care coverage. Even Congress is considering this as a way to expand the State Children's Health Insurance Program (S-CHIP), which covers working families making too much to qualify for Medicaid.
But in state capitols, results have been mixed for tobacco tax-funded health proposals. Lawmakers in Delaware, Maryland and Oregon rejected the idea, while Indiana and Iowa went along. Wisconsin Gov. Jim Doyle (D) is promoting a similar plan.
Tobacco taxes are attractive targets because smoking leads to many health problems. But the tradeoff is a double-edged sword: If higher taxes result in reduced smoking, less money will be available for health programs, said Enrique Martinez-Vidal, acting director of State Coverage Initiatives , which helps states expand health-care coverage.
Lawmakers in New York and Hawaii had this spring's biggest successes, both approving programs that would cover all children in their states.
New York Gov. Eliot Spitzer (D) convinced his Legislature to provide government-subsidized insurance for kids in families that earn up to four times the federal poverty level ($82,600 for a family of four). And lawmakers approved a three-year pilot project covering all kids in Hawaii, although Gov. Linda Lingle (R) still must sign off.
At least nine other states (Alaska, Indiana, Minnesota, Montana, North Dakota, Oklahoma, Utah, Texas and Washington) passed laws this spring to reduce the number of children without health coverage, according to a Families USA analysis.
Meanwhile, proposals to cover all residents in Illinois and Pennsylvania met stiff resistance this spring and are unlikely to pass. Still unclear is the fate of Gov. Arnold Schwarzenegger's (R) ambitious plan to deliver health insurance to all Californians.
With 6.6 million Californians lacking insurance, the state trails only Texas in percentage of uninsured residents. The potential deal-breaker: Schwarzenegger's proposal relies on money from doctors, hospitals, employers and taxpayers.
Illinois Gov. Rod Blagojevich (D) suffered a stinging defeat when the Democratic-controlled Illinois House voted 107-0 against his proposal to finance expanded health coverage through a new business tax.
Pennsylvania Gov. Ed Rendell (D) encountered resistance, too, when he sought to impose a fee on companies that do not provide workers with health insurance. Rendell doesn't expect the Legislature to take up a universal coverage proposal until fall.
Universal health care has become a popular goal in state capitols, especially after Massachusetts last year required all residents be covered by July 2007. In addition, Illinois and Pennsylvania led the way in offering medical insurance for all their children, and several Democratic governors used the promise of universal child coverage to win re-election in November.
Roughly one in seven Americans, 44.8 million, lack health insurance, according to the U.S. Census Bureau. That includes approximately 9 million children.
But cost, as always, remains a big concern. Governors' proposals to expand health coverage to the uninsured next year would cost more than $18 billion - $12 billion from California alone - according to a recent analysis by the National Association of State Budget Officers.
Oklahoma approved a big expansion of S-CHIP coverage by tapping $8 million from tobacco taxes and the national tobacco settlement.
But Republican-controlled legislatures in Arizona and Kansas shot down as too costly major expansion plans by their Democratic governors.
Kansas Gov. Kathleen Sebelius did win a study commission that will suggest ways to expand coverage. The law also provides subsidies up to $3,200 per family to help 24,000 families buy insurance starting in 2009.
Martinez-Vidal of State Coverage Initiatives said state policymakers increasingly are seeking ways to keep health expenses in check even as they try to broaden coverage.
For example, Washington state enacted a wide-ranging package of reforms this spring expanding coverage for kids and retooling incentives to encourage quality care. The lawmakers also took a page out of the Massachusetts book by allowing workers to use pre-tax dollars to purchase coverage.