It was a gutsy piece of legislation when it passed in 1992, born of bitter battles and a bipartisan belief that Minnesota families shouldn't have to be on welfare to get affordable health care.

The result was the birth of MinnesotaCare, a state-subsidized health insurance program for working families who earned too much to qualify for Medicaid yet couldn't afford private coverage.

"Like a fine bottle of wine, it gets better with age," former Gov. Arne Carlson recalled about the legislation that passed under his watch.

Considered by many as a prelude to today's federal health reform efforts, MinnesotaCare will celebrate its 20th anniversary this year -- and simultaneously see its demise, at least in its current form. Portions of the groundbreaking health care program don't comply with the Affordable Care Act.

The future of MinnesotaCare will be one of several pressing health care issues facing legislators when they arrive at the Capitol in January.

"The question is, how do we keep this rich history moving forward?" asked Jim Koppel, deputy commissioner for the Minnesota Department of Health, who helped craft an early framework for universal coverage that shaped MinnesotaCare. "How do we sustain it?"

Starting in 2014, many MinnesotaCare enrollees will become eligible for the expanded Medicaid program, the joint federal-state program that covers health care benefits for low-income families.

But community advocates fear that others could fall through the cracks, depending on how lawmakers design the new insurance exchanges. They worry that subsidies may be insufficient and that plans offered on the exchange could double or triple out-of-pocket costs for thousands of working adults.

"If the state doesn't take advantage of the opportunity to keep and improve MinnesotaCare, then thousands of working adults will lose the coverage that they can afford," said Liz Doyle, associate director of TakeAction Minnesota.

A three-hour celebration of MinnesotaCare last week at the Minnesota History Center drew current and former lawmakers, policy wonks, activists, lobbyists and beneficiaries of the program. They assessed the program's history, lauded its concrete successes and lamented its unrealized goals.

MinnesotaCare's vision, said Department of Human Services Commissioner Lucinda Jesson, was "breathtakingly broad." To date, it has helped more than 750,000 Minnesotans get insurance. About 148,000 a month are currently enrolled, with children accounting for 35 percent.

Eligible enrollees pay a portion of their premiums, and the rest comes from a 2 percent tax paid by doctors, hospitals and other providers plus federal Medicaid funds. It is offered for those whose workplace insurance is too expensive compared with wages or for low- and moderate-income Minnesotans who have been uninsured for at least four months.

The Affordable Care Act is more generous in many respects, said Lynn Blewett, director of the State Health Access Data Assistance Center. MinnesotaCare caps hospitalization coverage at $10,000, which doesn't go far if you have a heart attack or a chronic disease. The exchange will cover comprehensive inpatient, outpatient and mental health services.

Welfare reform

MinnesotaCare was passed as part of welfare reform of the late 1980s and early 1990s, as efforts to get people working and out of poverty failed when they or their children got sick.

Minnesota established the Children's Health Plan in 1987 to provide insurance for children who didn't qualify for Medicaid. MinnesotaCare, which essentially extended the same coverage to their parents, eventually replaced that program.

"We thought it would be a temporary bridge of three to five years, until the Clinton administration could get universal federal reform passed," chuckled Jim Hart, a retired physician and medical and public health educator who remains a single-payor advocate.

The road to eventual passage took two tries and a name change -- the program started out as HealthRight until it ran into trademark issues with a California company.

The process spawned caustic battles among lawmakers and interest groups. Hospital and physician groups staged protests over the provider tax, and insurers feared that people would leave the private insurance market and flock to the government program. Legislators received hate mail and death threats.

Carlson had just been elected governor when lawmakers delivered a bill to overhaul the state's public health programs, to the tune of $500 million. It landed with a thud as the state faced a $2.3 billion deficit. Carlson vetoed it and sent lawmakers back to the drawing board.

"It was one of the most grueling, long-suffering events I've ever been through," said former Sen. Duane Benson, an Independent Republican and member of the "Gang of 7," a bipartisan group of legislators who sandbagged themselves in a Capitol meeting room and hammered out a bill that would improve care, focus on prevention and be self-funding to avoid the whims of state budgets.

Bipartisan effort

Given today's polarized climate over health care, MinnesotaCare now is celebrated as a near-extinct example of bipartisanship: It bridged ideological differences between free-market believers and backers of a government safety net.

Former Sen. Linda Berglin, a DFLer and chief author, pined for elements of the bill that were rolled back, eliminated or never updated, including the $10,000 hospitalization limit.

Yet she hailed the core underpinnings of the program for the way it redistributed the funds: Doctors who provided more expensive services were taxed more, yet that money was invested in low-cost services, she said.

MinnesotaCare still fell short of its goal of universal coverage. Today nearly 60 percent of uninsured Minnesotans are eligible for some public program. Some elements that were never implemented look an awful lot like "accountable care organizations" and other elements of the current federal reform effort.

For Leslie Martin, a professional editor and writer, MinnesotaCare was a "lifesaver."

She's a two-time cancer survivor who lives with chronic depression and anxiety, and when her husband lost his job in 2010, buying health insurance on the private market was out of reach, given her preexisting health conditions.

The couple were uninsured for seven months, and Martin found herself cutting her antidepressant pills in half or skipping doses. Now with coverage, "a burden lifted off my shoulders," she said. She implored lawmakers to expand MinnesotaCare.

"Without MinnesotaCare, I would be struggling to be an active, working, contributing member of society."

Jackie Crosby • 612-673-7335