By David Willis

BBC News, in Los Angeles



Governor Schwarzenegger's plan could prove too ambitious

With Congress stalled on enacting a nationwide plan, individual states are starting to take matters into their own hands.

In California, Governor Arnold Schwarzenegger has just won approval from legislators for a major healthcare reform which will expand coverage to most of the state's uninsured.

It took nearly a year of sometimes fractious haggling, but legislators in America's most populous state have done what many predicted they could not

They have approved a bill to extend health insurance to virtually everyone in the nation's most populous state - all 36 million of them.

True, the measure has still to be approved by the state Senate and ratified in a popular vote, but it is nonetheless a considerable achievement.

A national template?

A jubilant Arnold Schwarzenegger emerged to hail the vote a "giant step forward".

LA's Skid Row area has become notorious for 'patient dumping'

He believes the un-glamorously titled Health Care Security and Cost Reduction Act could eventually provide a template for the entire nation.

But ironically, the greatest opposition to his plan comes from members of his own party.

Republican lawmakers point to California's $14bn (£7bn) deficit as evidence that the so-called Golden State cannot afford such an ambitious measure.

Other opponents argue that it will lead to tax increases - from a governor who previously vowed not to raise taxes.

The governor's plan would require all Californians to obtain health insurance by 1 July 2010 - providing subsidies for those who would otherwise have struggled to pay the premiums.

It would promote preventive care and also compel insurance companies to spend 85% of those premiums on patients - which is music to the ears of people like Maria Watanabe.

I thought that when you had insurance you had access to any treatment that you needed

Maria Watanabe, patient

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A few years ago crippling headaches prevented her from performing the most simple of tasks.

Ms Watanabe - who moved to Los Angeles from the Philippines - was denied a brain scan by her insurance company despite repeated requests from her doctor, only to be diagnosed with a tumour during a family visit to Japan.

"I thought that when you had insurance you had access to any treatment that you needed," she told me, tears welling in her eyes.

"If I hadn't gone to Japan maybe I wouldn't be here now. I would never have had the chance to know what was causing me so much pain."

Dickensian tableau

Just as the insured are sometimes denied coverage, so those without coverage sometimes find themselves dumped on the streets.

Rev Andy Bates has seen cash-strapped patients made destitute

Skid Row in downtown Los Angeles encompasses 50 square blocks of the city and is home to about 800 people sleeping rough.

Some, with no health insurance and no home, were literally dumped there by hospitals because they could not pay the bill.

Even in the Californian sunlight, it is a scene straight out of Dickens - a seething tableau of desperation and drug-addiction, figures huddled in dark corners or splayed out on the pavement.

I took a tour of the area accompanied by the Reverend Andy Bates, who runs a mission which offers food, housing and medical care to some of the area's regulars.

In the course of a year and a half he documented more than a hundred examples of "patient dumping" on Skid Row.

He told me: "I've seen a lot on these streets, but nothing compares to the woman who was dropped off in a hospital gown, an [intravenous drip] still in her arm, who died 10 minutes later in our reception area of pneumonia - discharged simply because she couldn't afford to pay her hospital bill."

Under Governor Schwarzenegger's plan, employers, hospitals and cigarette smokers would share the cost of funding California's healthcare reforms.

Lobby groups will inevitably attempt to derail the scheme, yet cost may prove the greatest obstacle.

There is widespread agreement in America that healthcare reform is badly needed, yet it is a massive task, and if the wealthiest state in the union cannot pull it off, any hope of a nationwide solution may start to seem bleak.