Let states choose health reforms

As strong supporters of President Barack Obama, we watched his latest speech on healthcare with great interest. Days later, we reviewed the latest offering on healthcare from Senate Finance Committee Chairman Max Baucus (D-Mont.). As the debate continues, it is becoming increasingly evident that whatever healthcare reform legislation passes this year will not result in anything like healthcare for all.

Medicaid expansion is being watered down as the debate rages. If an individual mandate survives the legislative meat grinder, the subsidies now proposed for many working families are going to be insufficient to make insurance affordable for most. And with the public option unlikely to prevail, costs will continue to rise exponentially, making further expansion of health coverage that much more difficult.

So here is a suggestion from one “shovel-ready” local government — Maryland’s Howard County — where our boots are already on the ground in the battle for better health: If the current national healthcare reform efforts fall short, let’s encourage individual states to take up the endeavor.

This approach would be similar to what the federal government has proposed with its new “Race to the Top” educational program. The program is a contest in which states, districts and unions can increase their chances of winning federal financial aid ($4.35 billion of support is available) with their unique education reform proposals.

The idea of having states lead the way in healthcare reform was first suggested a decade ago by the late Sen. Paul Wellstone of Minnesota. In this model, the federal government would offer significant subsidies to states that made good-faith efforts to provide affordable, quality, comprehensive health coverage to all their residents. States could do this by passing legislation that provided for cost controls and full coverage. And most importantly, the states would be held accountable by the feds for meeting the goals of their plan.

By providing adequate subsidies, the federal government would kick-start efforts in states that were interested in providing healthcare for all but would otherwise not be able to afford to try it on their own. To avoid judicial interference with these efforts, and to insure that all contribute their fair share, federal ERISA waivers would have to be granted to each state participating in the initiative.

States could try any approach they wanted, so long as it resulted in affordable, comprehensive coverage for all — single-payer systems, public-private collaborations, non-profit co-operatives, health savings accounts or other tax incentives would all be possible alternatives. To ensure accountability, robust five-year evaluations would be required of each state’s approach, looking at health status changes of their population, potential hospital and emergency room costs averted due to widespread access to preventive and primary care, whether the system slowed the increase in costs of healthcare in the state, and overall satisfaction with the new system among patients and providers alike.

Allowing several participating states to be incubators for change would show which system or systems worked best, and those could then potentially be replicated regionally or nationally. The results of the evaluations of different types of reforms in the participating states would provide the critical information missing in the national debate on healthcare reform — right now, although there is some evidence that certain components of reform are effective (like value-based payment), there really is no proof that any of the proposed systems would improve health and control costs. With this experiential evidence in hand, proponents of national healthcare would have the ammunition to counter many of the arguments thrown at current proposals, some of which stick because they are given the benefit of the doubt — a doubt that would be removed if we had good evidence to the contrary.

An additional benefit of reforming healthcare at the state level first is simply getting the debate out of Washington, which seems to be increasingly dysfunctional at figuring out what works on a human scale. The partisan gridlock and rule by lobbyists is less entrenched on the state level, and the media glare that brings out excessive partisanship is less extreme. Instead of imagining what a proposal might mean, we could see and weigh results, as we’ve done with our program to cover the uninsured in Howard County. The country could follow the lead of pioneer states, saving money and time in the process.

Whatever reform of America’s broken healthcare system that can be accomplished in Washington over the next few months should be applauded. But we cannot stop there and wait another 10 or 15 years for another grand, national campaign to fix the remaining problems. That is not fair to the tens of millions who suffer without any or adequate insurance, nor can our challenged economy sustain the growth rate of healthcare expenses. Let the states lead the way in showing how they can improve care, cover the uninsured, and control runaway health costs. The Wellstone approach is a smart way to go about it.

Ulman is the executive of Howard County, Md.; Beilenson, M.D., M.PH, is the county’s health officer.

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