Those cracking sounds you’re hearing from out in the country are the first political fissures in the bedrock opposition to universal health care. Fifteen years after the medical insurance industry did in “Hillarycare” with its “Harry and Louise” television advertising, we may have reached a political tipping point on fundamental reform.

It’s not only that a number of states have already acted or are working on the issue, but also that powerful interests — big business, labor, the elderly, health care professionals, and the hospital, managed care and insurance industries — all seem to be changing past positions and forming unlikely coalitions to push for change.

The states have the opportunity to serve as the “laboratories of democracy” that everyone always talks about, taking varied approaches toward the same goal so the nation might learn what works and what doesn’t. More than 46 million Americans lack insurance, and the number is growing even in a healthy economy, which is unusual.

In each of the three small states that have created universal coverage programs (Vermont, Maine and Massachusetts), the populations of the uninsured are relatively small: below 11 percent. But now some states with significantly larger uninsured populations are working on plans, among them New Mexico (21.1 percent), California (18.8 percent uninsured) and Illinois (14.2 percent). Their challenges will be greater: There are more uninsured in California than residents of Massachusetts.

Still, Massachusetts was important because the deal made by a Republican governor and a very Democratic Legislature has given leaders in other states some confidence that there is plenty of political wiggle room on this issue. People want something done, and they don’t reflexively oppose the idea of government involvement in the solution, as long as there is some market mechanism provided by the private sector.

The state to watch now is California — not only because of the size of its population and its problem, but also because it seems to have the will to take action if only it can come up with a way. Gov. Arnold Schwarzenegger and some Democrats in the Legislature want to require that everyone purchase insurance, with subsidies provided for those with low incomes, a mirror of the program Massachusetts is implementing. The governor’s plan — requiring patients, employers and medical providers to share the burden — is the most ambitious. But it appears Schwarzenegger intends to serve as a broker between his administration and factions in both political parties at the state capital to cut a final deal.

What is different now from 15 years ago, when first lady Hillary Rodham Clinton tried to get a national universal coverage plan off the ground, is the emergence of some very unusual alliances pushing for change. Last month, a coalition of 38 companies, most in the Fortune 500, announced a campaign to promote a plan similar to Schwarzenegger’s. The coalition is led by Steve Burd, the chairman of the Safeway grocery chain, who was influential in forming the governor’s proposal, and it includes members from the managed care, pharmaceutical, insurance and consumer product industries, as well as some power utilities and railroads.

An even more unusual coalition — the national Business Roundtable of large corporations, the aggressive Service Employees International Union and the AARP — announced in January that they had come together to push for overhauling health care, targeting both Sacramento and Congress. And a third self-described “strange bedfellows” coalition — including insurers, drug companies, doctors' groups, the AARP and a liberal-leaning health care advocacy group, Families USA — also formed at the start of the year, with expanded coverage for children its initial priority. It would be hard to think of more diverse groupings of interests than those, and it remains to be seen if they can stick together as complicated proposals are negotiated.

But clearly we have reached a turning point on the issue. As more states enact laws with differing balances of public and private involvement, we’ll have an opportunity to see what works. And what doesn’t, because unlike Washington, states have to balance their budgets; and when revenue slows down, as it inevitably will, many of the programs may turn out to be unaffordable. Massachusetts has already had to make compromises in implementing its program. Some of the projections for California’s plan are considerably more than the $12 billion the Schwarzenegger administration is estimating.

Most every analyst of states’ efforts to expand insurance agrees that if they are to succeed, Washington must not cut Medicaid or the program to provide insurance for lower-income children, which together cover almost 60 million people, because those programs are a foundation of the state efforts. But the Bush administration remains opposed to any state initiatives that increase costs to the federal government, and both of those programs are jointly funded.

So we may have to wait for a new administration to get Washington and the states on the same page. But it is far less likely that we’ll be hearing from Harry and Louise this time around.

Peter Harkness is the editor and publisher of Governing magazine, published by Congressional Quarterly Inc.