If our health care system is to be reformed, it looks as if it will be the states experimenting with different plans that set the direction for a national solution. Just three weeks ago, in a ceremony in Boston’s historic Faneuil Hall, the Republican governor of Massachusetts shared a stage with the leaders of the nation’s most Democratic state legislature to sign landmark legislation ensuring medical coverage for every citizen of the state. The mood, enhanced by a fife and drum corps and “Making History in Healthcare” banners, was congratulatory. Gov. Mitt Romney declared that “an achievement like this only comes around once in a generation, and it proves that government can work when people of both parties reach across the aisle for the common good.”

Indeed, some of the hyperbole was justified. The Massachusetts law is comprehensive and creative in its approach, constructed with help from insurers and health care experts in and outside the state. What makes it unusual among reform efforts is a requirement that all residents of the state purchase medical insurance by July 2007.

Projections are that the statute will bring coverage to almost all of the population, although its effectiveness will be determined by the quality of its implementation. The unique feature of the law is the creation of a private, state-chartered market mechanism, called the Connector, to match individuals and workers in small businesses with affordable insurance policies. Its intended effect is to pressure the insured to accept fewer benefits and higher deductibles and the insurers to lower their premiums. Rather than the one-size-fits-all approach most states have taken, the Connector is designed to tailor benefits to meet individual needs.

The law expands Medicaid coverage, especially for children, and subsidizes health insurance premiums for low-income residents on a sliding scale. More individuals and businesses will be able to purchase their policies with pre-tax dollars, while those who can afford insurance but don’t buy it will be penalized on their taxes.

The unanswered question, of course, is cost. For the first two years, everyone agrees the new plan is solid financially, relying on existing federal and state funding along with a fee of $295 per worker for small businesses that don’t provide any insurance.

What happens in the third year is problematic. A lot of things have to work just right in the implementation. And the state cannot afford either a reduction in federal funding or another fiscal downturn like most states experienced in recent years. Legislators say they might have to revise the law as problems become apparent.

There are critics of the law on the left and right, but those who argue that it won’t work financially are the most persuasive. First, they maintain that the number of uninsured has been significantly undercounted and that many of them require more medical attention, making it harder to find plans they truly can afford. They also argue that the plan does little to reduce costs, especially for administrative overhead.

No one really knows how well it will work. But we do know that we’ve been disappointed before. Twenty years ago, another governor of Massachusetts, Michael Dukakis, pushed through a law requiring businesses to provide health insurance, a plan he would tout in his run for the presidency as the 1988 Democratic nominee. Dukakis wasn’t elected, and the law was quickly repealed. Twelve years ago, Tennessee passed an ambitious expansion of Medicaid, well beyond federal guidelines, and for a number of years it seemed to be working. But state revenues slowed in the recession, and the Democratic governor, Phil Bredesen, was forced to remove at least 170,000 from the program last year. “TennCare was and is a wonderful dream,” he said in sadness. “It appears this morning that the dream is over.”

Now Bredesen, who once ran one of the nation’s largest health maintenance companies, is back with a new plan, called Cover Tennessee, that he claims is “more sensitive” and “more business friendly” than the Massachusetts law. It would offer optional and affordable coverage for low-income workers and small businesses, with the state paying a third of the premiums, but limiting benefits, such as the number of nights for hospital stays.

Maine is in the third year of another complex plan that addresses the entire health care dilemma holistically, touching on everything from providing insurance for everyone, to driving down costs, to managing chronic disease, to prevention. Some health care experts think it’s an all-encompassing plan that holds the best chance for success. The problem is that we won’t know for some time.

So far this year, at least eight states are looking at universal health care plans, and seven more have commissions studying it. Romney is likely to center any campaign for the GOP presidential nomination in 2008 on his success in passing one, even though experts agree that the Massachusetts plan would be hard for most states to replicate.

If a national solution is to bubble up from the country, we may have made a start.

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