The basic idea behind health care reform is simple — make sure most, and if possible all, Americans have adequate health coverage. After that, it gets complicated.

One difficult, but necessary, reform will be the expansion of Medicaid, which provides more than $300 billion annually in federal and state funds to help the poor, who otherwise could not get insurance.

More than 60 million Americans, including 245,000 in Hawai'i, depend on Medicaid for basic health care. But in this recession, demand is rising as resources are falling. With the unemployment rate skyrocketing, more people are losing their employer-based coverage or the means to buy their own. Those still clinging to their jobs are seeing their incomes drop as struggling businesses reduce employee hours and pay.

And states, including Hawai'i, are facing falling tax revenues and are struggling to balance their budgets. Rightly or wrongly, they respond by cutting back coverage to save money.

It's imperative that Congress, working closely with the states, adopt health care reforms that break this downward cycle.

Access to basic medical services can keep people healthier, out of emergency rooms and lessen the overall financial burden on the health care system. No American should get sick or die simply for lack of insurance.

In the last nine months, Hawai'i saw a 12 percent increase in the number of people qualifying for Medicaid, according to the Department of Human Services. At the same time, Hawai'i is facing a severe fiscal crisis — a $1 billion budget shortfall. About $1.4 billion in state and federal funds is spent on Medicaid in Hawai'i annually. DHS uses enrollment caps and other limits placed on coverage to keep costs manageable. Even so, DHS delayed $43.5 million in payments to providers in May and June because it didn't have the money, said DHS director Lillian Koller.

It's these kinds of untenable options that health care reform must correct.

So it's promising that Congress is considering expanding coverage by allowing people who earn more than the federal poverty level to qualify — proposals range from 133 percent to 150 percent. It's also important that Congress not water down current proposals for the federal government to cover 90 percent or more of the cost of the expanded pool of patients.

But with the recession severely crimping state budgets, state officials are rightfully wary about some details of various proposals under consideration. Echoing other states' concerns, Koller worries that Congress will impose overly restrictive national standards for minimum coverage, leaving Hawai'i without enough flexibility to manage its Medicaid plans based on local needs.

U.S. senators from 14 states — including Hawai'i — also have complained that their states, which provide more coverage than the federal government requires, could initially receive less federal support than other states that are lagging and need to catch up.

These are legitimate concerns. An expanded Medicaid program won't help anyone if it can't be paid for or managed efficiently.

Congress needs to work with the states — its Medicaid partners — to provide broader, efficient and effective health care to those who need it most.