Looking Back, Looking Ahead

PROLOGUE: Initiative on health reform bounced back and forthcontinuously between Washington and the states in the 1990sagainst a backdrop of rising costs, growing numbers of uninsured,and constant tension over managed care waivers in Medicaid.Out of the controlled fury of these struggles came devolutionand a new flexibility in state/federal relations. Among thefirst fruits of the new federalism was the State Children’sHealth Insurance Program (SCHIP). While qualified by problematicinteractions with welfare reform, SCHIP’s successes appearedto suggest that a more sensitive equilibrium between state andfederal roles could pave the way for further progress in coveringthe uninsured.

Still, some difficult questions remain unanswered: how the burdenof new subsidies might be distributed or how equity, accountability,and cost-effectiveness could be achieved? Each of the followingthree papers offers an overview of how the experiences of therecent past may condition the choices that lie ahead. Takentogether, they present a picture of dangers and opportunitieshanging in an excruciatingly suspenseful balance.

"Catalytic federalism" is the expression coined by Larry Brownand Michael Sparer to describe the synergy that opened the wayfor SCHIP, by giving states the latitude and the money to designprograms that pursued appealing goals but did not provoke cripplingpolitical antagonism. Alan Weil examines the unappreciated potentialof incremental design decisions for influencing, and perhapslimiting, future strategies for further coverage expansionsand applies this approach by analyzing a few aspects of competingproposals for tax credits and program expansions. Finally, LindaBilheimer and David Colby review the history of coverage policysince 1980 with particular attention to the difficult trade-offsthat have faced policymakers every step of the way, even underrelatively favorable economic conditions.

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Looking Back, Looking Ahead