In a process more akin to badminton than lawmaking, the state House and Senate have been batting House Bill 4021, an attempt to bring universal medical insurance to West Virginia.

The bill appears headed for conference committee and ultimate resolution. This is a good thing. And few, it seems, truly appreciate why.

For those who have not followed the saga, some background: Two elements have remained constant. Both House and Senate versions of the bill contain the governor’s pilot program to allow primary care clinics to charge a monthly fee for their services, much as fitness clubs do. The idea is to encourage people to establish a medical home and assure access to preventive care and disease management, both eminently worthy goals. Both also contain the governor’s Affordable Insurance program, often referred to as the $99-a-month “basic” plan. In fact, many will pay considerably more than that figure. The program allows insurance companies to offer much less for much less — fewer benefits for a lower price.

The House added an expansion of the Children’s Health Insurance Program (CHIP) from 200 percent of the federal poverty level to 300 percent (from $40,000 to $60,000 for a family of four) with the possibility of fewer benefits and the imposition of premiums. Simultaneously, Senate Health Chairman Roman Prezioso took up a dormant Senate bill doing the same. This would leave just under 3 percent of West Virginia’s children without health insurance — a major accomplishment.

The contentious provision, appearing and reappearing in the transit of the bill between chambers, has been House Speaker Bob Kiss’ proposal for future planning and, hopefully, action. The original House proposal added a new health care reform commission with the goal of providing full coverage to all citizens by 2010. The Senate stripped out the commission as inconsistent with the governor’s original initiatives. The House put the proposal back in, assigning two existing agencies, the Health Care Authority and the Insurance Commission, the duty of assembling study committees and reporting yearly on cost-neutral strategies to provide greater access and increased benefits. The Senate rejected the revision. The House declined the opportunity to concur with the Senate version.

While the two houses lobbed the bill back and forth, a critical issue was at stake: whether West Virginia will even have a forum for seeking new ways out of the current health care morass.

Few seem aware that almost all the formal studies and proposals affecting the uninsured in West Virginia during the past four years had been funded by a Health Resources and Services Administration state planning grant. These efforts benefited from a broad range of participants and the time necessary for full deliberation. Ideas arrived at the Legislature fully vetted and with a built-in consensus. That was then. This is now. The HRSA grant program ends in August.

Confronted with the potential loss of a formal forum for advancing the debate, House Health Chairman Don Perdue and Senate Chairman Roman Prezioso have apparently stepped forward and found common ground. This is important. The final bill will enable a new process of strategic planning toward the ultimate goal of quality, affordable health care for all West Virginians.

At the same time, one must not be overly enthusiastic. Although the governor proclaimed this “the health care session” and claimed he was taking “bold steps,” even small steps have been hard to come by.

A new venue for dialogue has been established, yet past history warns against undue optimism. Almost all of the recent initiatives have been based on the dual principles of no new state money and a reliance on commercial insurance. This in a state in which 53 percent of the 220,000 uninsured nonelderly adults earn less than $20,000, and 79 percent are below $30,000!

Real and lasting solutions to the health-care crisis require broad long-term reform. There is little evidence to suggest this can be accomplished with the usual people meeting around the usual table coming up with the usual proposals. There is a truism in health care that each stakeholder has a solution that benefits them. For each, the second-best choice is the status quo. Government administrators, burdened with maintaining existing programs, seldom have the luxury of imagining radical alternatives. Bureaucrats are constrained by existing funding and reimbursement regulations. Industry is driven by a fiduciary responsibility to its stockholders. Who, then, is to look out for society as a whole?

Let us savor the victories, but keep our eye on the prize. Incremental change may be the only change on the horizon. That need not be so bad if we strive to direct that change toward a vision of a more efficient, effective, affordable and equitable health care system. One can only hope the recent détente proves a positive omen in that endeavor.

Kurland is health action coordinator of Covenant House and creator of the Web site www.criticalread ing.com. He served on a state medical planning task force.