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KAI RYSSDAL: It's 26 days until Election Day. Not that anybody's counting or anything. Politicians are out there, asking for your vote. But are they saying anything else? On the tough issues that don't have easy answers? Today on our fall election coverage, The Real Agenda, health insurance.

About 46 million Americans don't have any. And the federal government hasn't tried to do anything about that in more than a decade. Vermont and Maine have provisions for virtually everyone to be covered. But Massachusetts has taken by far the most dramatic steps. From the Marketplace Health Desk at WGBH in Boston, Helen Palmer reports.

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HELEN PALMER: Just 10 days ago, Massachusetts Governor Mit Romney showed up in the parking lot of Neponset Community Health Center in Boston's gritty Dorchester area. He was there to launch the state's new program to cover the uninsured: Commonwealth Care.

ROMNEY: Now this is a historic day for us. Today is the first day that we have someone actually apply for Commonwealth Care. It's real today.

Romney — widely tipped as a GOP contender for President in 2008 — introduced that essential political prop: the sympathetic real person who'll benefit.

MADELINE RHENISH: I never thought I would be in a position where I wouldn't have and couldn't afford health insurance.

She's Madeline Rhenish, a 56-yearr-old who worked on community development projects till she got sick and lost her job and her health insurance.
RHENISH:I exhausted all my retirement savings. I paid out-of-pocket for those medical expenses I absolutely had to pay, and tried to figure out what other expenses — food, gas, other necessities — that I could cut back on or delay paying. Romney says that'll change now. Rhenish can sign on to Commonwealth Care. And so can some 50,000 other state residents who earn up to the federal poverty level of $9,800 a year. They'll get first-class health coverage at rock bottom prices — just a $1 to $3 co-pay.

ROMNEY: They can receive regular preventive care, prescription drug coverage, mental health coverage, comprehensive hospitalization coverage. They receive it without a deductible and without paying a portion of their premium.

The state invited commercial insurers who specialize in plans for Medicaid to craft this coverage. By next July, they'll roll out plans for Massachusetts residents who earn up to three times the federal poverty rate — that's $60,000 for a family of four. So where will Massachusetts find the cash to pay for all this?

JOHN GRUBER: Essentially what this bill amounts to is a rededication of money we were already spending to care for the uninsured.

That's John Gruber. Gruber teaches economics at MIT.

GRUBER: There was a lot of money the state was already spending on caring for the uninsured — much of it from the federal government — which is nice, because it's not our money, it's someone else's. And some of it from the state in the form of taxes on employers and insurers and health care providers.

Washington kicks in $385 million a year, and has committed to pay that for the next two years. On top of that, all the stakeholders help share the cost. The newly insured will pay on a sliding scale related to income — a family with two kids that earns three times federal poverty level would pay a premium of $268 a month.

And employers with more than 10 workers must offer health coverage or pay the state $295 a year for every employee. That's a modest charge, says Gruber, but businesses detest it.

GRUBER: This was a compromise which the business interests were willing to put up with. And to their credit, they were willing to put up with something despite the sort of camel's nose under the tent argument against anything.

Observers say that's the important thing — the whole bill's a compromise between competing interests — not only business and government but Democratic lawmakers and the Republican governor. Still, some medical providers see pitfalls. Dan Driscoll runs a network of community health centers.

DAN DRISCOLL: The plan is intended to be cost-sharing between the insurance company and the patient — the patient pays a part of it.

But what if the patient can't afford the co-pay? At the moment, state cash pays the health center if patients can't but most of that pot of money will go to this insurance experiment.

DRISCOLL: We won't turn away people who can't afford to pay their part, so it could end up being cost-sharing between the insurance company and us the provider.

Some policy experts argue there just aren't enough dollars to make the new program work. But it has a better shot here than other places — Massachusetts is rich, it has few uninsured residents. Health advocates say one thing's certain. The Massachusetts model will fundamentally shift the political debate — at least for next year, thanks to Mitt Romney's presidential ambitions.

John McDonough of the group Health Care for All:

JOHN MCDONOUGH: The fact that you've got a leading candidate for the Republican nomination saying universal means that any Democrat who wants to say "Let's just do some incremental improvements" is going be out of kilter with what the expectation will be.

And similarly, Romney's role in the Republican race means that it'll be a changed conversation on the Republic side on healthcare.

In Boston, I'm Helen Palmer for Marketplace.