In lieu of an abstract, here is a brief excerpt of the content:

1 chapter one Federalism Creates Health Policy Friends in my small town know that I have been involved in national health care reform efforts as well as those in our home state of Massachusetts. When conversation at the local pub turns to health care, they’ll ask me questions. Because I’m a political scientist, not a medical doctor, I don’t get pelted with questions everywhere I go, so I welcome the opportunity to respond. I only wish that there were better answers. Jack, a salesman for a high-tech company, thought that the Massachusetts health care reform would allow him to cover his 24-year-old daughter, Meghan, on his employer’s health plan. So why did his company tell him that she wasn’t covered? I try to explain that larger companies are exempt from state insurance regulations because they self-insure; those businesses use insurance companies like Blue Cross or Aetna only to administer their claims. It is confusing because the same insurance companies actually provide insurance to small businesses, and in those cases they are subject to state regulations. Eyes glaze over, and we quickly return to the fortunes of the Boston Red Sox. Meanwhile, Meghan remained uninsured. Matthew runs a small financial consulting business. Because of doubledigit health insurance premium increases, coverage for him, his wife, and their three boys takes a big bite out of their budget. He wanted to know whether health care reform would offer more reasonably priced health plans. A while back, I had told him that help was on the way: Massachusetts had just created the Health Care Connector, which was intended to provide a choice of plans at lower prices, at least in theory. The Connector did expand coverage to lower-income individuals and families, but it did not lower the cost of insurance for people like Matt and his family. Perhaps I should have told him to hold tight for federal small business tax credits? Or let him know that 01-2483-4 chap1.indd 1 6/25/13 5:34 PM 2 / federalism creates health policy health care exchanges created by national reform may offer a better solution soon? But at the risk of losing credibility and a good tennis partner, I turn back to discussing the ball game. As the country geared up for national health care reform, I traveled from state to state talking about reform efforts in Massachusetts. Everywhere I went, I shared my excitement over the obvious progress in coverage. More than 98 percent of people in Massachusetts have health insurance, by far the highest coverage rate in the nation. Enacted in 2006, state reform added a patchwork of new programs and regulations that built on previous expansion efforts. Over 300,000 previously uninsured individuals now have health insurance coverage and can sleep better at night. But the program is complex and difficult to comprehend—even for policy wonks—and it was not designed to address persistently rising health care costs. National health care reform was signed into law by President Obama on March 23, 2010. The Patient Protection and Affordable Care Act (ACA) has much in common with the Massachusetts effort. It holds similar promise— and suffers from similar limitations—when it comes to expanding health care coverage to the uninsured. More of the uninsured will be covered, but coverage will be complex to negotiate and cost containment will be just as difficult. Despite its shortcomings, ACA represents a significant political triumph after a series of failed efforts that date back to the Truman administration .1 Under national guidelines, reform will be administered in large part by the states through existing health plans, insurers, hospitals, doctors, and other health care providers.2 States will be critical players in implementing reform and in establishing state-based health care exchanges. Applying national exchange rules to health systems that vary widely from state to state will be a tremendous challenge. The ACA barely passed Congress, along partisan lines. The Democrats struggled to hold on to more conservative members of their party and used parliamentary maneuvers to avert defeat by filibuster in the Senate. The Democrats in the Senate did not even have the votes to include a relatively modest “public option” insurance plan to help balance private sector offerings and force down administrative costs. However, it is unlikely that anything more progressive could have passed. In fact, after the 2010 election, when the Republicans gained control of the House of Representatives and the conservative...

Share