An Oregon initiative with a realistic chance of passage this week would create the first program in the nation that would offer a Canadian-style universal health care program to all state citizens.

By the time you read this, Oregon voters will have passed judgment on Measure 23, the "Oregon Comprehensive Health Care Finance Plan." Over recent months, Measure 23 has galvanized volunteers, gathered national attention, spotlighted the largely ignored frustration much of the public feels with the horrific state of America's health care delivery system, and drawn the fierce opposition of the health insurance and hospital industries. It's the first time in eight years voters in any state have had the opportunity to approve such a system.

The initiative claimed over 3,000 volunteers across Oregon and thousands more donors, while opponents, by mid-October, had gotten only about 50 donations--primarily from the health insurance industry. But with over $400,000 in hand, those groups are outspending proponents by more than 10 to 1. Kaiser Permanente, Regence BlueCross BlueShield of Oregon, Pacificare, PacificSource, and ODS Health Plans each donated more than twice the total received by the Yes on 23 campaign.

Independent polling has been scarce, with polling conducted by each side showing that they're ahead; most observers have given opponents a narrow but easily reversible lead. As the numbers of undecided voters has decreased, Yes On 23 says, the measure's support has steadily improved.

For those of us accustomed to a system of jumbled and inadequate access to care and coverage, the scope of the Oregon plan is staggering. The agency that would supervise the system would cover virtually all medically necessary procedures for virtually all state residents, including those not now insured. That includes any number of medical procedures for which, under existing HMOs or insurance plans, patients now must pay some or all of the cost--among other things, alternative practitioners, premiums, co-payments and out-of-pocket costs for doctors, dentists, home health supplies, prescription drugs excluded by private health insurance and Medicare, and long-term care. Residency requirements would be notably lenient; to qualify, all a new resident would need to do is declare their intent to remain in the state.

The price tag, not surprisingly, is enormous. In a state of 3.4 million residents, the plan would cost an estimated $20 billion per year--more than the entire current budget of an already cash-strapped state. Proponents claim two-thirds of that money would be covered by reimbursement from existing federal and state programs, leaving at least a third--critics say it's more like half--to be raised through higher income and other taxes. Those taxes would be progressive; the 25% of population below 150% of federal poverty level would be exempt from income tax increases. But critics charge that the tax burden, and the spending, will skyrocket in the future, particularly as residents realize they can obtain medical services they don't currently use--or cannot now afford.

"Right now in the US we're spending almost $4700 per person per year on health care," Britt McEachern, one of the organizers behind the measure, said last month. He claimed that proposed tax increases would "...be completely offset for most people by the money they save. You're going to limit copayments, insurance premiums, deductibles, you're not going to pay out of pocket for prescription drugs..Most people are going to wind up saving a lot of money."

There is, of course, another potential catch: the federal government must agree to a waiver to redirect money now going to the state's existing low income health system, the Oregon Health Plan, which Measure 23 would supplant. And the Bush Administration, according to all observers, is likely to be hostile to a comprehensive, state-run system that essentially puts insurance companies out of business in the state. Oregon already has experience with the feds destroying a progressive state ballot measure; as with several Western states, Oregon voters have overwhelmingly approved legalization of medical marijuana, but programs to make such use viable remain blocked by federal intransigence.

Such concerns have led to some surprising groups declining to back Measure 23. The Oregon AFL-CIO is opposing it, on the grounds that it would increase taxes too much for working people; labor wants a universal health care system, but wants employers to pay for it. The Oregon Medical Association, which has long backed some sort of universal health care coverage, has also come out against the measure, due to concerns over the cost and the likelihood of not being able to gain federal reimbursement.

Despite these criticisms, McEachern was upbeat; he can draw upon the discontent of voters alarmed and angered at the expensive and inadequate health care they now get from the HMO system. He also sees Measure 23's passage as likely to spark similar efforts in other states. "Right now," he says, "there are 13 other states pursuing universal health care. Oregon is the furthest along. When it passes here every one of those campaigns will kick into a higher gear."

The question, ultimately, is whether anger over the sorry state of Oregon's current health system is so pervasive that voters in a state historically willing to try new ideas will go for a system that is costly, unproven, and likely to raise hackles with federal programs. In the end, if Measure 23 won last Tuesday, it may be due to its opposition. "[Measure 23] is not going to help the insurance companies one bit," McEachern says. "It's gonna help citizens." And anything that pisses off the insurance companies has got to be a good idea. And even if Measure 23 loses this year, our health care system is still in a state of crisis--and other states with initiative processes, like Washington, can certainly try again.