With healthcare problems continuing to mount in South Florida, regional leaders say the most they can hope for out of Washington is some kind of limited change.

That's their thinking after hearing President Barack Obama's State of the Union speech on Wednesday night in which he vowed to keep fighting for reforms:

``Here's what I ask Congress . . . Don't walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people.''

Those remarks came 30 minutes into his speech, after discussing Pell Grants and child-care tax credits, reflecting the new reality: The Massachusetts Senate election earlier this month killed the possibility of getting the current proposals through Congress.

Steven Ullmann, a health policy specialist at the University of Miami, noted that Obama talked about the need for health insurance reform -- as opposed to healthcare reform. And by inviting Republican ideas, the president implied that ``we're going to see something more bipartisan in nature.''

``It will be more limited, something acceptable to both parties,'' predicted Brian Keeley, head of Baptist Health South Florida, who has been following the legislation closely. `Or it could be dead on arrival, a possibility that everybody's so chagrined about that they don't want to mention.''

Keeley, like most South Florida healthcare leaders, believes changes are absolutely essential. ``We have a finger in the dike -- and the dike is going to crush us.''

Miami-Dade already has among the highest healthcare costs in the nation, and a huge number of uninsured. Miami-Dade has 28.1 percent uninsured -- almost twice the national average -- and Broward isn't far behind at 21.8 percent. In Hialeah, census data shows 53.1 percent have no coverage. In Pompano Beach it's 39.6 percent.

Hospitals and other providers raise rates to cover the costs of uninsured, and each time rates are raised, more employers can't afford coverage. ``We don't have a sustainable system,'' Keeley said.

Many healthcare leaders are alarmed about the sagging fortunes of Jackson Health System. The government system is estimating a loss this fiscal year of almost $90 million. Among other things, it's ending its contracts to pay for outpatient dialysis.

A group of hospitals are now talking about picking up those dialysis costs, partly to keep the kidney patients out of their emergency rooms, but their unspoken fear is that Jackson might keep curtailing services, creating a tailspin that other hospitals couldn't afford to pick up on.

The overhaul process halted abruptly with the election of Scott Brown in Massachusetts, a Republican replacing one of the most vocal supporters of healthcare reform, the late Sen. Ted Kennedy.

Frank Maderal, a Hialeah gastroenterologist who is president of the Dade County Medical Association, said that when the Brown victory was announced, he had finished a monthly column analyzing details of what the reform bills would mean to South Florida doctors. ``I had already sent it to the printer. I had to change everything.''

``I hope it's not totally dead,'' Maderal said. Many of the uninsured in Miami-Dade would get coverage, if it were affordable and if they weren't rejected for preexisting conditions. ``Something needs to get done. It'd be a help just to get rid of preexisting conditions'' restrictions.

But there's a problem with that, said Robert Berenson, a physician who is a fellow with the Urban Institute. Trying to insure a few more people without providing something close to universal coverage is ``a slippery slope.''

By banning preexisting clauses, ``only sick people would sign up for insurance,'' Bereneson said. Well persons would be less likely to waste their money on coverage. That would mean that either insurance rates would be enormously high or insurers would go bankrupt.

``So to do away with preexisting, you have to have some kind of mandate that people must have insurance,'' so that well persons could contribute to the pool of funds insurers could draw on, Berenson said. ``And that means you're back to full reform.''

Alberto Casaretto, a nephrologist who is president of the Broward County Medical Association, said his colleagues are more concerned about short-term issues, such as the looming possibility that doctors' Medicare rates will be cut by 20 percent if Congress doesn't act by the end of February. ``These are very significant issues.''

At the South Florida Hospital and Healthcare Association, President Linda Quick said, ``I'm an optimist. I think the status quo is untenable, particularly in South Florida, and it won't work for a lot longer.

``I like the fact that the president said he isn't quitting [on reform] and he said the Congress shouldn't either. Something needs to get done.''