Minnesota health plans and the state's largest physicians group have been quite vocal in recent months in pushing for a requirement that all Minnesotans have health insurance. Blue Cross Blue Shield of Minnesota even created a universal coverage model to get the debate started.
That model estimates it will cost $911 million to subsidize the state's 383,000 uninsured Minnesotans. The plan is deliberately short on important details, like the actual amount of individual subsidies. Blue Cross officials say that's up to lawmakers and others to figure out.
The legislative debate is still months away. But there's no shortage of debate now among Minnesotans who will likely be affected by the proposal. One of them is Isaac Fuhr.
Fuhr, 30, walked away from his $70,000 a year civil engineering job in June 2006 to start up his own carpentry business. He took a big pay cut to do it, and he gave up his health insurance.
"It was really hard," he says. "My wife is not happy about it and she wants us to get coverage as soon as possible. We're trying to look at all the options."
Fuhr ruled out continuing his coverage from his previous employer, because he would have to pay more than $800 a month for his family of four. Fuhr doesn't think he can afford much more than $200 to $250 a month for health insurance. He did find a plan with catastrophic coverage that was close to that price range.
"But I got denied through Medica by one of those high-deductible plans because we visited two different marriage counselors in the span of a year, and it's considered mental health," says Fuhr. "It's a bummer that they wouldn't cover us now because I didn't know that they could do that."
What is the cost? If you're going to mandate it you've got to make it affordable.Isaac Fuhr, who is uninsured
But as much as Fuhr wants health insurance for his family, he has mixed feelings about proposals that would require him to buy it.
On the one hand, he thinks it's great that the Blue Cross proposal would forbid insurers from denying him coverage. And he's more than happy to receive a state subsidy to help him buy insurance. But Fuhr says he worries the subsidy will be paltry and he'll be forced to buy insurance he can't afford.
"What is the cost? If you're going to mandate it you've got to make it affordable," says Fuhr. "You can't just say, 'You have to have insurance and you're going to pay this much for it.'"
The Blue Cross proposal doesn't spell out exactly what individuals or families should pay for their insurance. The company wants public debate to shape the formula. But the insurer does suggest a model that the state could use to guide its thinking -- MinnesotaCare.
Colleen Reitan, president and CEO of Blue Cross Blue Shield of Minnesota, says the publicly subsidized program should be expanded to include people like Fuhr.
"We have many of the mechanisms we need already in place, in order to help us get to universal coverage," Reitan says. "We have a very effective and successful program that was enacted by the Legislature in 1992 called MinnesotaCare, and that's for lower-income working people."
People enrolled in MinnesotaCare pay premiums based on a sliding fee scale that ranges from $4 a month to more than $500 a month, depending on family size and income.
Blue Cross recommends broadening MinnesotaCare eligibility. For example, an individual who earns up to $30,000 a year would qualify for the program.
But that idea doesn't appeal at all to Isaac Fuhr. MinnesotaCare caps coverage at $10,000 a year for hospital stays. So Fuhr's assets, like his home, wouldn't be protected if he got seriously injured on the job or if one of his family members developed a catastrophic illness.
"It's kind of the opposite of what I'm looking for. I guess it's good for people that need to go to the doctor a lot. But it's bad for people that if something really bad happened, you're not covered," says Fuhr. "I want the opposite. I want it if something really bad happens, I'm covered."
Blue Cross does recommend that the state help pay for private insurance for people who qualify for a subsidy, but aren't interested in MinnesotaCare. Fuhr says the state's subsidy would have to be substantial for him to afford purchasing health insurance for his family of four in the private market.
Fuhr isn't alone in his concern about cost.
On a cool, damp Friday morning, Laura Leasman, 27, is enjoying a few spare moments in her kitchen before heading off to her part-time job as a nanny.
Leasman is a student and if all goes well, she will graduate from the University of Minnesota in the spring with a degree in clothing design -- and thousands of dollars in student loans.
This year some of her loans have gone to help pay her health insurance. The University requires Leaseman to have coverage. She pays $740 each semester for it.
"There was no way around it and I just had to do it. I mean, I can't quit school because I'm not going to take the school's insurance," she says.
Leasman has mixed feelings about her mandated coverage. While she is somewhat relieved to have insurance, she doesn't think she gets enough for her money.
"I basically think of myself as uninsured. I have insurance, but it really wouldn't cover it even if I did have something happen," says Leasman. "I'm still hoping I don't get sick. and don't have to go to the doctor for the next year and potentially beyond."
Leasman says she wouldn't want to be forced by the state to buy a skimpy insurance plan like the one she has now. She says she probably couldn't afford the type of plan with substantial benefits that allowed her to see just about any doctor she chooses.
She's hoping to avoid the issue altogether by getting a good job after graduation with good insurance benefits.
Her mother Nancy Leasman hopes that happens, too. Nancy Leasman worries that a universal coverage mandate would undermine insurance for everyone else.
"I know it would be easier for her, certainly, and other young people who have difficulty affording the insurance. But for those who are paying for it then they're paying twice, because the money has to come from somewhere in order to pay those subsidies," she says. Leasman is also skeptical about the motives of those pushing for universal coverage.
"It just seems kind of un-American to require it, when I know that the insurance companies are making a lot of money," says Nancy Leasman.
Colleen Reitan of Blue Cross has heard all of this before and she expects to hear more of it in the months ahead. She says she welcomes the debate.
"We made the decision as a company that people could shoot at us for lots of reasons, wonder about what our motives are. And we feel good about what our motives are, and the goal is to get the lowest number of uninsured," Reitan says. "And we made the decision that we had a responsibility to really speak out, and throw some ideas out and see where we could move the conversation."
It's not clear yet if lawmakers will consider a universal coverage mandate during the next legislative session. That depends in part on the outcome of statewide elections in five weeks.
But supporters say their ranks have grown considerably in the past year, along with their determination to move this issue forward.