Interest Groups and Health Care Reform across the United States

5 Universal Health Care in the States

ChaPter 5 Universal Health Care in the States During the 1990s the states and the federal government addressed many of the same health care issues—universal coverage, regulation of managed care, and prescription drug coverage for seniors. But, as we have seen, the outcome was often different, with health reforms being enacted later or not at all at the federal level. In chapter 3 we saw that by 2004, thirty-four states had passed some kind of pharmaceutical assistance law, using state funds to pay for a portion of the cost of drugs for eligible senior residents. In chapter 4 we learned that between 1994 and 2001, the fifty states passed more than nine hundred different laws regulating managed care. But in this chapter we examine a diffusion process with a different policy outcome. Despite a number of incremental policy events—studies, bill introductions, the passage of laws by one or both legislative chambers, and sometimes the signing of these bills into law—the states collectively have not been successful in achieving universal health care coverage for their citizens. At the national level, however, on March 23, 2010, when President Barack Obama signed the Patient Protection and Affordable Care Act (ACA), the nation took a major step toward (near) universal care. But even this comprehensive legislation did not contain a “public option,” that is, a publicly sponsored health plan that would compete with private insurers to drive down premiums and ultimately health care costs. Such an option was first proposed in California (Halpin and Harbage 2010), was picked up by presidential candidate John Edwards during the 2008 campaign, and was ultimately endorsed by candidates Hillary Clinton and Barack Obama. The public option was included in the House of Representatives bill, but not in the Senate bill due to Senator Joe Lieberman’s filibuster threat as well as the opposition of the Republican Party and its interest group allies. However, the public option could still be reborn at the state level, where a state may offer such an option through its new insurance exchange; indeed, that is just what the state of Vermont did in 2011 when it enacted Green Mountain Care, a single-payer plan. Thus, the analyses in this chapter may help serve as a road map for understanding states’ actions in the future as they develop their insurance exchanges. 124 | CHAPTER 5 We are interested in the states’ failures as well as their policy successes for several reasons. First, we want to know if the same forces credited with impeding national health care reform for so long have also limited state efforts to secure universal coverage. As explained in chapter 1, at the national level, organized interests are often credited with stymieing broad-based reform of the health care system.1 Have the same organized interests also blocked universal health insurance legislation in the states? Second, why have the states been so successful in regulating managed care organizations and adopting pharmaceutical assistance programs, but less so in enacting and sustaining universal coverage? Examining the determinants of policy activity on universal coverage enables us to compare these results with our similar studies on more successful health care policies in chapters 3 and 4. We return to this question in the book’s final chapter. Third and more broadly, we are interested in the prospects of incremental policy reform versus policy punctuations. That is, the states have hardly been inactive in trying to expand access to health insurance. Studies have been commissioned and bills have been considered and sometimes passed into law, even if less often implemented. Did these incremental steps take us anywhere? Berkman and Reenock (2004) assert that policy activity in the past can make full-fledged reform more likely in the future. Or, as suggested by Baumgartner and Jones (1993, 2002; Jones, Sulkin, and Larsen 2003; Jones and Baumgartner 2005), does real policy reform require a punctuation in which comprehensive coverage laws rapidly diffuse across the states? Fourth, we are interested in how the vertical diffusion process worked in universal health care: How did the failure of President Clinton’s health care plan proposal spur states on to develop their own plans? And how did the experiences of state health care plans, especially that of Massachusetts, affect the development of the ACA in 2010? We investigate these issues by first reviewing the history of efforts to promote universal health care in the states. The next section constructs a model of policy activity on universal coverage based upon...