Washington lawmakers are working to decrease the number of state residents who have little to no health insurance coverage, and five proposals for health-care reform—separately introduced in past sessions in Olympia—have been identified for possible action by the full Legislature in 2010.

The proposals are currently undergoing a cost-benefit analysis, and the Legislature might decide to adopt one of them, create a hybrid version, or draft something new. It also is possible there will be no reform. Legislators and others say a lot will depend on who is elected as the state's next governor and the nation's next president this fall.

State Sen. Chris Marr, D-Spokane, who serves on the Senate's Health Care Committee, says, "I don't see large-scale reform on the horizon." At least not in the next session, which starts Jan. 12, he says.

Robby Stern, chairman of the nonprofit Healthy Washington Coalition, which is made up of health-care organizations, consumer groups, labor, and small business, says the nature of any health-care reform will depend on a variety of political and economic factors, including the outcome of the cost-benefit analysis, and the result of the state and national elections next month.

Over the last five years, health-care costs for the typical Washington household have increased more than six times faster than family income, Stern says. Since 1993, employer-based coverage in the state has declined from 71 percent of employers to 66 percent, he says.

The increasing costs are driving more people into the ranks of the uninsured or underinsured, he says.

"The escalating cost of health care is having a profound effect on the economy for both individuals and businesses," Stern says. "We have a fragmented, inefficient system where 30 cents of every dollar goes to administrative costs," such as billing and record keeping.

During the 2008 legislative session, a Senate bill calling for an analysis of proposals for health-care reform, including one to establish a single-payer system similar to Canada's, was passed. That bill resulted in the five health-care reform proposals being selected for the current cost-benefit analysis.

In addition to the single-payer proposal, one of the other four plans being analyzed would modify insurance industry regulations, permitting companies to offer more limited coverage, with the cost of coverage could be determined by a person's age, with younger people paying less.

Another is the Massachusetts plan, which requires nearly all adults to carry health insurance, and the state to penalize employers who don't offer coverage. One of the two other plans would cover all Washingtonians with a comprehensive, standard benefit package, and the other would guarantee catastrophic coverage and basic preventive care.

Mathematica Policy Research Inc., a Princeton, N.J.-based nonpartisan policy research firm, has been contracted by the state to do the economic analysis of the five proposals.

As part of the Senate bill calling for comprehensive analysis of such proposals, the governor early next year must appoint nine citizens—representing business, labor, health-care providers, and consumer groups, along with experts in health-care financing and ethics—to a state health-care reform work group. Four legislators, representing each caucus of the Senate and House, also would serve on that group.

The work group will review Mathematica's analysis of the proposals and begin a public process that is to end in a final report in November 2009, summarizing its work and making recommendations to the governor and the Legislature.

One major factor driving up health-care costs is the number of uninsureds, who seek medical care at hospitals and in emergency rooms, where it's more expensive, without seeing a primary care physician or other practitioner first, legislators say. A second major factor is administrative costs, which are eating up too much of what is being spent on health care, they contend.

State Sen. Mark Schoesler, R-Ritzville, says he wants costs reduced, but doesn't see the issue of cost being addressed by the proposals selected for analysis.

"There hasn't been any movement towards something that's more of a compromise, more of a market-based plan," says Schoesler. "If the light of day is shed on these plans, (backers) will have a hard time convincing the state of Washington that it is ready for Medicaid-style insurance and mandates."

The plans all represent "one version or another of socialized medicine," Schoesler says. "These plans are more about universal coverage and mandates than cost containment."

More input is needed from employers, and more flexibility for businesses and consumers is needed, he says, adding that a one-size-fits-all approach won't work.

State Sen. Karen Keiser, D-Kent, chairwoman of the Senate Health Care Committee, says she has been visiting different cities across the state this summer and fall, joining in roundtable discussions about the ailing health-care system and potential solutions to its problems.

"We cannot continue to do what we've been doing," Keiser says. "What we are doing now will break the bank. We need to increase access, improve quality, and also reduce costs."

It's going to be difficult, she says, to find ways to reduce the number of uninsureds in the state from the current level of roughly 700,000. Plus, she says, she worries that group could be growing in number, especially in a bad economy.

"There's no silver bullet," she says. "It's going to take several initiatives at every level."

The state has been hit by a "double whammy," she says, pointing out that health insurance is costing more, and fewer people are being covered.

Keiser sees a need for expanded use of electronic medical records, to provide consistency and accuracy. Administrative costs are too high, she says, and could be lowered with uniform billing.

"Every doctor is spending two hours per day on insurance," she says.

She sees a need for a purchasing agent consortium for prescription drugs, a need for increased primary care, provided by family physicians, and a need for more preventive care, particularly for kids.

State Sen. Cheryl Pflug, R-Maple Valley, the ranking minority member of the Senate Health Care Committee, says most of what she's seen in the proposals identified for analysis are variations of the Canadian single-payer system, which she contends would have the government taking over. Also, the proposals aren't focused on fixing what she considers to be the primary problem—reducing the escalating cost of health care, she says.

Pflug says that to reduce costs, it's critical to keep the uninsured from receiving their health care in hospital emergency rooms as a last resort. She says roughly half of Washington's uninsureds are between the ages of 19 and 34. Getting those younger, and usually healthy, adults insured would go a long way toward reducing costs for everyone, she says.

She says the private insurance deregulation plan being analyzed now could address that problem. That plan would allow health-care plan premiums to be adjusted to reflect a consumer's health status, and would allow for the health risk of young adults to be addressed separately and for them to be charged lower rates than other enrollees.

She says the focus shouldn't be on where people get their insurance—whether it's from the government, their employers, or independently. Instead, she says, the focus should be on what the insurance is buying for each person.