Health Care Pushed to Fore By Calif. Vote

Still, the issue of health care has the ability to create the kind of stories that force reactions from candidates. Just this week, news organizations focused on a 17-year-old girl who died on Thursday hours after her insurance company reversed its decision to deny her request for a liver transplant.

Nataline Sarkisyan had leukemia and received a bone marrow transplant from her brother. But she developed complications that caused her liver to fail. Cigna HealthCare, her insurer, turned down a request earlier this month to pay for a transplant, saying the procedure was experimental.

Though Cigna reversed itself in the face of protests, including a rally of 150 teenagers and nurses outside its offices, Sarkisyan died several hours later at the University of California at Los Angeles Medical Center. On Friday, her parents said they will sue Cigna.

Passage of the health plan by the Senate is by no means assured. Senate President Pro Tem Don Perata (D) has withheld endorsement of the bill, referring to the need to study the state's $14 billion budget deficit.

And voters themselves must approve the funding mechanisms, including a steep new tax on tobacco and a surcharge on hospitals. Although polls show strong support for the package in principle, history has shown that ballot measures are far easier to defeat than to pass. Opponents, led by Blue Cross of California, will have almost a year to campaign against it before the November ballot.

"A tax is a tax, and even though the preponderance of California voters won't feel it, it has that mantra," said Jaime A. Regalado, executive director of the Edmund G. "Pat" Brown Institute of Public Affairs in Los Angeles.

Republicans warned that many elements of the measure remain untested. And a Sacramento Bee columnist noted ominously that Assembly Speaker Fabian Núñez and Schwarzenegger hammered out many of the bill's details behind closed doors; in 1996 that kind of secrecy produced a bill that deregulated California's energy market and "turned out to be a humungous disaster" when it contributed to the state's energy crisis years later.

But the health package impressed some experts by finding compromises where earlier efforts ended in logjams.

The measure requires all residents to acquire health insurance but helps pay for coverage for families who earn as much as 450 percent of the poverty level.

That subsidy is funded largely by employers who choose not to offer coverage; they are required to pay from 1 to 6 percent of their payroll, depending on the size of the company.

The measure also requires insurance companies to spend 85 percent of premiums on health care, limiting overhead to 15 percent.

"That is precedent-setting," said Karen Davis, president of the Commonwealth Fund research group, which last week issued a study projecting savings of $1.5 trillion nationwide from reforms along the lines of some of the California provisions.

Davis noted that California has a long history of innovation in health care. Los Angeles doctors pioneered managed care for aqueduct workers in 1908, and Kaiser Permanente started as a health program for San Francisco Bay shipyard workers in World War II. But efforts to legislate universal coverage foundered for decades here, as in Washington.

"For a long time, this was seen as too big, too complicated, too costly, too many interest groups," Davis said. "When you get action by a major state like California that has a very high level of uninsured, it just becomes realistic and pragmatic: This is doable. What is really needed is leadership."