The New Politics of State Health Policy (review)

Over the past decade, states have enacted an extraordinary array of health care policies, including public insurance expansions, efforts to regulate the emerging managed care industry, and initiatives designed to deal with the pernicious influence of tobacco. The various authors in The New Politics of State Health Policy do a wonderful job of describing these (and other) innovations, along with the institutional arrangements (in the legislative, executive, and judicial branches) that produce them. For this reason alone the book is a worthy addition to the library of anyone concerned with either the evolution of health policy over the past decade or the options and opportunities for reform in the near future.

The book is divided into three sections: an introduction to the institutional context of state health policy (with chapters on federalism, governors, and legislatures); a review of several current controversies (the backlash against managed care, SCHIP [State Children's Health Insurance Program], mental health managed care, public health, tobacco, and the debate in Oregon over health care rationing); and chapters by Jim Morone, Robert Hackey, and Thomas Oliver that provide broader perspectives.

The chapter by John McDonough and Robert McGrath on state legislatures provides an especially good overview of health politics at the state level. As the authors note, prior to the 1970s, state legislatures were considered inept, corrupt, and generally unprepared to tackle hard policy issues. Over the past thirty years, however, most state legislative bodies modernized (more staff, more professional legislators, greater policy-making capacity), though the interstate variation in each of these variables remains large and the political and fiscal backlash (reflected in term limits, campaign finance reform, and antitax voter referendums) presents additional challenges. Frank Thompson's excellent review of federalism presents a similar picture: state policy-making capacity is relatively strong, but there are still important limits and, equally important, it is hard to gauge state commitment to reform.

The chapters on current controversies echo the themes of uneven capacity and mixed commitment. David Rochefort's chapter on the backlash against managed care provides a good example. Rochefort begins with a nice summary of the rise of managed care, the reasons for the backlash against the industry, and the state (and federal) response. He then notes, however, that many of the new rules are more symbolic than substantive and that others may be weakly enforced, either because the industry may "capture" the regulatory agency or because the state simply lacks the administrative capacity to effectively enforce and implement. Despite this mixed record, Rochefort expects state regulatory activity to increase: the efforts are a low-cost way of responding to public dissatisfaction.

These limits (political, financial, administrative) prompt state officials to look for allies and partners in the effort to initiate reform. Sometimes the partners are other institutions of state government. State efforts to regulate the tobacco industry, for example, were aided immeasurably by the courts. Suzann Thomas-Buckle and Leonard Buckle describe the tobacco litigation and the judicial settlement that provided states with more than $200 billion. Sometimes the partners are private sector organizations. Chris Koyanagi and Joseph Bevilacqua summarize state efforts to delegate to managed care organizations the task of providing mental health benefits to Medicaid beneficiaries. The rise of mental health managed care is of course part of a larger state effort to encourage or require millions of beneficiaries to enroll in private sector health plans, an effort that continues today (albeit with diminished expectations and scaled back participation by the private sector plans).

The state's most important partner, however, clearly is the federal government, a point noted explicitly or implicitly throughout the book. In his introduction, for example, Morone notes that nearly every state health care program relies on federal financial participation. Thomas Oliver makes the same point in his concluding...