CHARLESTON, S.C. -- Two years ago, the nation's governors were wrestling with soaring healthcare costs, rising populations, and agonizing choices over how to keep their Medicaid programs afloat.
Now, as governors are holding their annual summer meeting, healthcare seems less hopeless. Their choices are vastly different as many states embark on unprecedented experiments to revamp the healthcare program for the poor, and healthcare overall.
Massachusetts has captured the spotlight with a universal health insurance plan that demands everyone in the state get insurance, and gives them help to get it. In different shapes and sizes, other states have begun experiments, from West Virginia to Idaho, Florida to Maine.
``There's an imperative for change out there," said Michael O. Leavitt, secretary of health and human services, who asked governors yesterday to join President Bush in demanding nationwide standards on medical quality and information-sharing. ``The system is moving."
The fall elections also are a major topic at the three-day gathering of the National Governors Association, which opened Saturday. Thirty-six states will elect governors this fall.
Governor Mitt Romney, who is attending all three days of the conference, made a presentation to the governors on how states respond to emergencies of various types, according to spokesman Eric Fehrnstrom. He also attended the session on the states' role in healthcare.
These are among the signs of change on healthcare:
Massachusetts created universal health insurance by requiring everyone to carry insurance, with a combination of subsidies and penalties to make coverage more affordable and encourage people to buy it.
Florida tried to rein in costs, starting in two large counties, by shifting many Medicaid recipients into private managed care. Medicaid recipients choose a managed care group to coordinate their care and the state pays a premium to the group. Companies will get more money for sicker patients.
West Virginia aims to encourage Medicaid families to make healthier decisions and save money by reducing benefits if they refuse to sign contracts promising to show up for doctors' appointments and use the emergency room only for emergencies.
Most programs are not yet in place or too new to assess whether the change is for better or worse, or even if they work. The overhaul in Maine -- which brings state and businesses together to get more people on insurance -- by Governor John Baldacci, a Democrat, is one of the oldest, though so far has failed to enroll the numbers of uninsured that it aimed for.
There is a partisan divide, too, as Republicans push many of the more ambitious plans -- though the changes in Massachusetts and Vermont only passed with Democratic help in their legislatures. Many Democratic governors are coming up with their own proposals.
``The current system is not working. The states are experimenting," said Governor Jennifer Granholm of Michigan, a Democrat, who is following the Massachusetts example with a proposal to create a more affordable private market for insurance, subsidies for the poor, and incentives to get more businesses to cover employees.
Healthcare analysts are monitoring the results. ``The question is, does this work?" said Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities, a liberal think tank. She's looking closely at programs that aim to encourage healthier, and more cost-efficient, decisions.
``A lot of states are really seeking different approaches to change behavior," she said. ``But the short of it is: it's not that easy."
While on one hand governors work on often-technical details of insurance markets and quality control, they are also targeting the nation's culture of eating and exercise.
The best solution is having a healthier population, said Governor Mike Huckabee of Arkansas, a Republican. ``Sick people aren't going to get cheaper. You can trim a few pennies, but we need to trim dollars."
That means getting people to live healthier, said Huckabee, who has made that goal the focus of his past year as governors association chairman.
The different elements come together as governors seek to rein in rising Medicaid costs, which have ballooned to about $275 billion.
The states pick up, on average, about 43 percent of the overall costs.
Leavitt said Bush would soon issue an executive order to demand doctors and hospitals that work with government to adopt standards on quality, information, and performance. He asked governors to do the same.