Health Affairs, 27, no. 2 (2008): 423 doi: 10.1377/hlthaff.27.2.423 © 2008 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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States' Role

PROLOGUE

States’ Role In Addressing Disparities

So in the annals of federalism and devolution, policies to rectify racial and ethnic disparities in health care present a somewhat unpredictable test case. States are better positioned than the federal government to intervene, since there is considerable local and regional variation in types and degrees of disparities. But do the states have the will and the wits to act? The question is of particular interest in an election year when state initiative looms large in debates about health system reform, and a referendum of sorts will be held on the devolutionary policies of the Bush administration.

The evidence from two studies that follow is mixed. In the first, Mara Youdelman assesses efforts by the states to mitigate barriers to access for twenty-three million U.S. residents whose proficiency in the English language is limited—a majority of whom, by the way, are native-born or naturalized citizens or documented immigrants. Federal law requires that providers who receive any federal payments can’t let language barriers interfere with access to services, but the reach of the federal law is incomplete. Youdelman documents far-reaching efforts by the states to fill the gaps, but also striking variation in the level of these efforts from state to state.

In the second study, Dolores Acevedo-Garcia and Lisa Cacari Stone find much variation in health insurance coverage for the U.S.-born citizen children of immigrant parents, depending on whether one or both parents are citizens. State policies and economic conditions affecting coverage vary widely and are sensitive to the effects of having a noncitizen parent in the household, which suggests the need for careful monitoring and nuanced policy making by the states. Brian Smedley, study director for the Institute of Medicine’s (IOM’s) landmark 2003 study of disparities, Unequal Treatment, wraps up this section with an overview of state policies to implement recommendations of the IOM study, which the federal government has done little to pursue.

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