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States |
PROLOGUE
The Role Of States
After years of near-paralysis in federal health care reform, it seems that much of the momentum driving efforts to expand coverage among the growing ranks of the un- and underinsured has shifted to the states. To some, enabling states to serve as "laboratories"—sparking new thinking and new strategies for increasing coverage, access, and even quality—makes perfect sense, as local actors are arguably best situated to respond to local circumstances. To others, this is a desperate last-ditch move, conceding the seeming intractability of entrenched positions that have long prevented the enactment of national reform legislation.
Relatively recently, the national spotlight has shined on Massachusetts as a model for state-driven policy making with the goal of universal coverage for its residents. The Massachusetts "carrot and stick" approach of individual mandates, coupled with a state-run insurance "exchange," ideally enables the uninsured to purchase portable insurance at regulated (read "affordable") rates. The level of national attention and scrutiny aimed at the Massachusetts model not only reflects the merits of the policy initiatives themselves, but also is testament to the degree to which the notion of states’ taking the lead in making policy to extend coverage has become conventional wisdom. Although key philosophical differences persist surrounding the precise configuration of the federal-state relationship governing states’ efforts to be the incubators of health care reform, the idea that states should be permitted to find local solutions tailored to local conditions represents a rare point of convergence even among perennially divided federal policymakers.
The papers that follow, while acknowledging this conceptual consensus, explore the divergence of thinking by illuminating two distinct approaches to configuring the federal-state relationship in this realm. First, Henry Aaron and Stuart Butler build upon earlier work published in Health Affairs in arguing for empowering states to take the lead by permitting case-by-case modifications of existing federal laws that could be barriers to implementation of states’ plans to expand coverage. In a companion paper, Alan Weil reflects a somewhat more pessimistic impression of states’ ability to achieve far-reaching impact among their residents even if permitted relatively free rein from federal legal and regulatory encumbrances. He intriguingly argues that a more assertive federal role within the state-federal partnership facilitating greater state experimentation, as opposed to the federal government’s merely "getting out of the way," carries with it greater potential for states to realize the maximum impact flowing from their various health care reform initiatives.
Related Articles
- Henry J. Aaron and Stuart M. Butler
A Federalist Approach To Health Reform: The Worst Way, Except For All The Others
Health Affairs, May/June 2008; 27(3): 725-735.
[Abstract] [Full Text] [PDF]
- Alan Weil
How Far Can States Take Health Reform?
Health Affairs, May/June 2008; 27(3): 736-747.
[Abstract] [Full Text] [Figures Only] [PDF]
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