The Ridge proposal, released late last month, earmarks $40 million to help hospitals defray bad debt and the costs of charity care. That represents 10 percent of the state's annual $400 million windfall from cigarette companies and is the clearest victory for the state's hospitals, industry lobbyists said. In addition, it's estimated that hospitals could end up with about $80 million in fees for services that would be provided under Ridge's plan to use $160 million of the annual payments to extend health-care coverage to the state's uninsured residents. Combined, the estimated $120 million would cover about one sixth of the $725 million that Pennsylvania hospitals said they spent on bad debts and charity care in 1998, the latest year for which figures are available. In addition to providing funds for uncompensated care and for the uninsured, Ridge's plan calls for spending the balance of the funds on home care for elderly people who otherwise would need nursing home care; education to prevent or reduce tobacco use; health-care research and ventures; and creation of an endowment fund for future tobacco-related programs. "All of those programs are programs hospitals provide," said Carolyn F. Scanlan, president of the Hospital and Healthcare System Association of Pennsylvania, a statewide trade group. Although hospitals were enthused that all of the tobacco money would go for health care in one form or another -- which is not the case in some other states that participated in the federal settlement -- some expressed concern about how the money for uncompensated care would be split among them. "The detail is what is missing," said Children's Hospital spokeswoman DeAnn Marshall. "The issue we have is where pediatrics fits into this." Ian Rawson, executive director of the Hospital Council of Western Pennsylvania, said it appears that individual hospitals will get shares of the money in proportion to the amount of uncompensated care they provide. "This could make a huge difference to hospitals in offsetting that expense," he said. Allegheny County institutions accounted for about 18 percent of the uncompensated care that Pennsylvania hospitals provided in 1998, according to the statewide trade group. The new insurance program for the uninsured would be similar to the state's Children's Health Insurance Program (CHIP) in that it would be separate from Medical Assistance, which provides coverage to the poorest adults and children. Most uninsured fall in a gap of coverage between Medical Assistance and private or employed-sponsored health insurance plans. As with CHIP, the state would contract with private insurers to provide coverage to uninsured adults with incomes below 200 percent of the federal poverty level -- about $16,500 for an individual and $33,400 for a family of four. Details of the governor's plan haven't been released, but state insurance department spokeswoman Angela Yarbrough said the working plan would require consumers to contribute $30 per month. The benefits package hasn't been spelled out either, but Yarbrough said subsidized health plans for the working poor that are already offered by the state's Blue Cross and Blue Shield insurers are serving as the model. Highmark Blue Cross Blue Shield's Special Care program, for example, charges individuals $58.50 per month for a limited amount of inpatient hospitalization coverage and some outpatient benefits, including emergency accident and medical treatment, surgery and diagnostic x-ray and lab services. But Fran Chervenak, a lawyer in Pittsburgh with the Pennsylvania Health Law Project, said the benefits package in Special Care is nowhere near as generous as the package available through Medical Assistance. Special Care lacks a prescription drug benefit, which means beneficiaries would have to pay out-of-pocket for medicine -- an increasingly expensive proposition, she said. The plan also lacks mental health and substance abuse benefits, and places limits on out-patient medical care that are more restrictive than in the Medical Assistance program, Chervenak said. Another problem for consumers is that the 100,000 people who could benefit from the governor's plan comprise only one-fourth of the people who need the benefits. Chervenak's organization said there are about 400,000 uninsured Pennsylvania adults living 200 percent below the poverty level. "Even though we think it's a good focus for the governor to use this for the uninsured, we think you can get more bang for the buck by expanding Medical Assistance coverage," Chervenak said. Another factor that might influence how far the state can stretch funds for the uninsured is the rate at which Pennsylvania's uninsured population is growing. While Pennsylvania still has a lower percentage of uninsured working-age residents than the nation as a whole, the percentage grew at more than double the national rate between 1991 and 1997, noted Scanlan, president of the statewide hospital trade group. Creating a separate program for adults further compounds a marketing problem that health-care advocates say the state already has with its existing health insurance programs. A parent can go all the way through the process of signing up for CHIP, for example, only to find that they are eligible for Medical Assistance and must start the process again, said Bob Nelkin, president of the board of directors at the Consumer Health Coalition in Pittsburgh. Other insurers in Pennsylvania said they would be interested in working with the state to provide the new benefit. "We applaud the governor and the state's desire to put a large investment toward the uninsured population," said Fran Soistman, president of HealthAmerica, a managed-care insurer offering health plans in Western and Central Pennsylvania. Soistman said any efforts to provide coverage to the uninsured should "benefit everyone" through a domino effect -- easing the financial strains that bad debts and charity care create for hospitals also eases the pressure on private insurers and health plans to pay and charge more for health-care services. But Soistman noted that other states attempting to structure insurance packages for the uninsured have met with mixed results. Often, basic benefits plans "have still been too expensive" for working individuals with lower incomes, Soistman said. "I think we need to make sure we learn from others' successes and failures."

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