Fixing U.S. Health Care: Can States Step Up Where Washington Has Failed?
Health Care

Fixing U.S. Health Care: Can States Step Up Where Washington Has Failed?


The midterm elections may have focused extensively on health care, but the results have done little to clarify where health care reform is headed. “The future of U.S. health care reform is muddier now than at any point in the past two decades,” write researchers from the Boston University School of Public Health, University College London and the Milbank Memorial Fund in this week’s New England Journal of Medicine. “[T]here is little reason to believe that substantive national action is likely any time soon,” they say.

That leaves states to fill the vacuum, they suggest — and so they surveyed state legislators serving on committees related to health, asking them to rank their policy priorities. They boiled down their results to four main themes that they say “generated widespread agreement across ideologies, parties, branches of government, and stakeholder perspectives.” The researchers then went to two states, Kansas and Colorado, to have discussions with leaders about their findings:

1. Washington isn’t helping. The lawmakers surveyed “expressed near-universal disdain for what was described as a dysfunctional and chaotic environment in Washington” — a political environment that state legislators said made their jobs harder. “It is difficult enough for state leaders to plan for the long term, given election cycles, short legislative sessions, and term limits,” the researchers write. “Strategic thinking is nearly impossible when Congress and the administration are unpredictable and volatile.”

2. Access to health care is a priority across the political spectrum. “Leaders on all sides stressed the challenge of ensuring that there are enough providers in rural communities,” the researchers say. And in both Kansas and Colorado, the researchers found that, “although there may be quibbles about the ACA, there does not seem to be an appetite for a large-scale rewrite.”

3. Both parties want to bring costs down. “However, though everyone we interviewed in Colorado and Kansas agreed that costs are a high priority, there was little agreement on the root of the problem or on whose costs should be prioritized. Costs to the government? Consumers? Hospitals? Providers? Are we actually talking about charges or prices instead of costs?” Bridging that divide will be a challenge.

4. Philosophical differences over the role of government are the biggest challenge. “Leaders were frustrated about this reality and eager to find ways to bridge this divide,” the researchers write. “One way members of both parties try to do so is by framing health policy conversations to acknowledge that it will be impossible to eliminate the role of government and that the key question, therefore, is how the public sector can get the most value for what it spends. Similarly, people on all sides expressed a desire to expand the scope of the conversation beyond insurance and medical care to the social factors that shape health, such as housing and employment, and to look at the proper role of government in that context.”

The researchers emphasize that, as we go through a period in which states are serving as laboratories of democracy on health care, policymakers should be looking at what is working and what isn’t in other states. “This period of state-level experimentation is an opportunity to develop evidence about the effects of everything from Medicaid work requirements to housing vouchers,” they suggest. “Then, if history repeats itself, their efforts will show the way for that lagging legislature in the District of Columbia.”