The current legislative session, the governor announced in his State of the State address, is to be devoted to health care. This is clearly appropriate. West Virginia — and the nation — has a health-care crisis. Costs are out of control. The number of uninsured, employed or not, continues to rise.

The governor’s key initiatives stem from work of the Affordable Insurance Workgroup (AIW) — on which I had the honor of serving. The group brought together a broad range of people with knowledge of the state’s needs and a real desire to do something about them. We were, however, bound by two constraints that essentially precluded long-term solutions.

The first constraint was “to do no harm” to the current health-care system. Read: Do no harm to the commercial insurance industry. Never mind that the cost of commercial insurance is increasing at a rate twice that of government insurance (Medicaid, Medicare). Or that roughly 30 percent of commercial health insurance goes to overhead (administration, marketing, profit, etc.) instead of to health care.

The second constraint prohibited additional government spending. New government initiatives — even those that might prove budget neutral in the long run — were off the table from the start.

Our AIW was instructed to design a plan affordable for individuals without the advantage of employer subsidies. In fact, full health insurance is increasingly beyond the financial reach of most people — even with employer subsidies! To be affordable to the poor, plans must radically limit benefits and cap expenses. The cost of health care is thus lowered by providing less health care, now called “basic, affordable health care.”

Under the projected plans, a woman 26 to 34 in age seeking a monthly premium under $100 could receive primary and preventive care (routine physicals, X-rays, physician office visits, prenatal care) and then be limited to a total of $2,000 in all outpatient services (MRIs, specialist care, etc.) over a year’s time. No hospital coverage, no vision, hearing or nonemergency dental services, and no coverage for brand-name drugs. Older citizens would pay considerably more.

Surely, some health insurance is better than none, and access to primary care may be sufficient for the majority of people, but it should not be mistaken for comprehensive health insurance. Is the glass half full or half empty? Is this all we can do? The AIW presented five possible insurance scenarios. Significantly, none of the proposals was wholeheartedly recommended by the workgroup members.

Another new program focuses not on insurance but on access to primary care. The pilot clinic-based program allows individuals to receive all primary-care services available at one of eight as-of-yet-unnamed primary-care clinics for a set monthly payment — potentially ranging from as low as $25 for public clinics to $85 for private clinics. Businesses may also participate, provided they have not offered other medical insurance for the past year — a “look back” provision designed to prevent companies from dropping existing policies for a cheaper and less comprehensive alternative.

Participating clinics must provide basic primary-care services, including basic lab tests, preventive services and disease management. Specialty care, and both inpatient and outpatient hospital care, as well as high-tech imaging (mammography, MRI, etc.) are not included.

The covered services, it should be noted, are currently available to all at publicly funded primary-care clinics on a sliding payment scale. Enrollment in the new plan, however, provides the security of a medical home and the continuity of services associated with that, as well as access to “340b” prescription drug prices (below Canadian prices) at federally funded health clinics. How much private clinics are in it for the profit has yet to be seen.

And yet even here, the governor’s bill makes sacrifices to the fears of the insurance industry. Overriding the recommendation of the AIW, he has extended the look-back provision to individuals. Most evidence actually shows that people who can afford full coverage will not drop it for cheaper and more limited plans. This is the same provision, many argue, that has seriously limited the effectiveness of last year’s Small Business insurance program.

When drowning, one must tread water to survive. Survival is good. But one must not mistake treading water for a sense that one is nearing the safety of shore.

Both proposed initiatives are necessary and worthwhile, however limited they may be. What’s missing overall is a vision of a health-care system that promises to provide affordable medical care for all — or even a strategy of looking for one. The governor offered a new program of five-year revenue projections; why not a five-year path to a real health plan?

In the end, it’s the vision thing. Other states have formed commissions to look at methods of providing universal, affordable coverage without the constraints imposed on the Affordable Insurance Workgroup. Indeed, the Legislature passed a resolution (HCR 9) in 2004 setting as a goal “to provide all West Virginians with comprehensive, quality, affordable health care... (and) it shall be the goal of all state agencies to formulate such a plan.”

In that vein, the pilot project on clinic-based primary care is particularly important. Not so much because it will provide immediate relief to a great number of people, but because, if found worthy of statewide expansion, it could mark an incremental step toward a more significant goal — universal primary care for West Virginians. Yet here again we need a vision of how specialty care and hospital care can be added to the mix.

Had this not been touted as “the year for health care,” one might not have expected more. But it was. And so we do. It is important that West Virginia be friendly to business. But if it is not also friendly to its citizens, what’s the point?

Now, under Speaker Bob Kiss, the House appears to be going in what Kiss called “a more aggressive direction.” Let’s hope it succeeds.

Kurland is health action coordinator of Covenant House and creator of the web site www.criticalreading.com.