With health-care reform stalled, debate heats up regarding state approaches

Texas Gov. Rick Perry lauds his state's health-care system, even though the state has the highest uninsured rate in the nation.
Texas Gov. Rick Perry lauds his state's health-care system, even though the state has the highest uninsured rate in the nation. (Pat Sullivan/associated Press)
By Alec MacGillis
Washington Post Staff Writer
Sunday, February 14, 2010

Proponents of leaving health-care reform to the states have gained momentum as national legislation stalls in Congress, setting off a new debate over who is best able to tackle one of the nation's thorniest social issues.

Advocates of a state-by-state approach are invoking welfare reform, which originated in the states, and education, an area in which the federal government goads states to improve but lets them choose their own approaches. Imposing national health-care reform, they argue, ignores local variations in health-care markets and politics.

"Let's let the states come up with the solutions," said Missouri state Senate President Charlie Shields (R). "There's a lot of solutions out there, but the solutions vary state by state."

Supporters of a national approach counter that relying on states would mean accepting the status quo for years to come. A state-by-state approach makes it harder to rein in health costs with systemwide reforms. And cash-strapped states are in no position to launch new initiatives. Shields acknowledges that Missouri won't be expanding insurance coverage to more people anytime soon, saying, "Other than just doing the right thing, there's not much incentive financially to do that right now."

And even in brighter times, the states with the highest rates of uninsured -- mostly in the South and West -- have shown little interest in expanding coverage.

"There just isn't the political will" in many states, said Jon Kingsdale, who runs the agency overseeing the Massachusetts health-coverage program. "To leave this to the states is not realistic -- it's what we did for the last 40 or 50 years."

The national legislation appeared on the verge of passage before the election last month of Sen. Scott Brown (R-Mass.) erased the Democrats' filibuster-proof majority. Brown has endorsed the federalist approach, saying he opposed the national legislation, even though it is modeled on the law that he supported in his own state. People in Massachusetts, he said, should not have to pay for coverage elsewhere when they already have near-universal coverage at home.

In another declaration of state prerogative, the Virginia Senate earlier this month voted to ban a mandate that individuals carry insurance, which is part of the national legislation.

But there are few major state initiatives on the horizon. California's Senate passed a universal-coverage bill last month, but Gov. Arnold Schwarzenegger (R) said he plans to veto it. The few health-related proposals in states tend to be narrow, such as requiring coverage for certain conditions. In fact, many states are reducing coverage for low-income residents.

Advocates for a federalist approach say states have been holding back to see what Washington will do. They argue that with the national reform efforts in doubt, President Obama and congressional Democrats should scale back and pass legislation that would set a few targets -- offering rewards to states that expand coverage by certain amounts, for example.

The proponents imagine a range of policies: Some states might copy Massachusetts, for example, mandating that people carry insurance and creating a regulated marketplace where they can buy it with income-based subsidies. Others might adopt a "single-payer" model, or use tax credits to help people buy coverage. The approaches that work best could be taken up by additional states.

"If you want a system that's continuously improving over time . . . that's less likely to happen if you lock in something at the national level," said Stuart M. Butler of the Heritage Foundation, a conservative think tank.

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