Why the laboratories of Democracy get it wrong on health care

 

 

With President Obama in the White House, we can look forward to the most vigorous and informed debate on health care in many years, possibly ever.

But as far as I”™m concerned, policy makers may look a bit too favorably on the attempts individual states have made to widen the health care safety net within their own borders. Justice Louis Brandeis famously said, “It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.” But when it comes to health care reform, state-by-state experiments won”™t work.

 

Not that state legislators haven”™t tried. Hawaii, Tennessee, Oregon, California, and most prominently Massachusetts have all experimented with schemes of greater or lesser scale. But none are a model program that can be emulated on a national scale, which is, after all, the only thing that matters when we are talking about “universal” anything.

 

One fundamental flaw is that all these schemes confuse health care with health insurance. They are not the same thing. Massachusetts, which some think offers the last best hope for achieving anything like universal health coverage in a single state, claims that 97 percent of its citizens are now insured. But what does that mean when family doctors are in such short supply that patients have to wait six months for a routine physical examination, as they do in many parts of the state? The routine physical is the bedrock of health care. In another example, Florida in 2008 announced that it would allow insurers to offer “no-frills” coverage to the state”™s 3.8 million uninsured residents. Residents ages 19 to 64 could purchase limited health coverage for as little as $150 per month; the policies would cover preventive care and office visits, but not care from specialists or long-term hospitalizations. Maybe it”™s just obvious to me, but “no frills” works better in airline travel than in health care; you can do without that free headset, but without specialty care, sick people are going to end up back in the emergency room, at greater cost to taxpayers than before.

 

Another factor works against state-by-state reform. Individual states may not have sufficient medical resources to serve their own citizens. For the same reason that states can”™t be self-sufficient in fossil fuels or in banking, they cannot be self-sufficient in pharmaceuticals and medical talent. They have to compete with the rest of the world, public sector and private, for energy, capital, and medical professionals and facilities. The imbalances are abundantly evident even within a state like Massachusetts, which has world-class teaching hospitals but cannot provide enough in-state primary care doctors for its population.

 

In addition, states can”™t fully control their health care policy and resources. They have to grapple with federal regulations and depend on federal funding. You may recall that Gov. Eliot Spitzer tried to expand eligibility for state-sponsored health insurance to families with incomes four times the federal poverty level. But he had to get a waiver from the federal government, and that waiver did not materialize. Still, a child is a child (and an adult is an adult) no matter where they live. All of them should have access to the same standards of health care, irrespective of the political inclinations of their state governor and legislature. Nor do we need the medical version of race-to-the-bottom commerce, in which states compete for corporate investment with low-ball tax rates, which ultimately leads to poor social services, bad schools and lax environmental standards.

 

Then, too, let”™s look at the universal tendency for government structures to take on lives of their own. Each additional set of rules, level of supervision and geographic boundary may make sense initially. But when the lines drawn become indelible, and the bureaucracies created to enforce them calcify, we move further from the goal of providing health care. Protecting jobs becomes an end in itself. Every one of the state health care schemes sooner or later founders for budgetary reasons, and the only available politically pragmatic cuts come at the expense of health care itself.

 

Reforming our health care system requires a nationwide solution. We need national bodies to determine standards of care, to evaluate health care information technology, and to decide on the appropriate use of federal dollars. That may not be as difficult as it looks, considering that the cost of Medicaid, Medicare, Veterans Affairs health care, and the government employee system already account for around half of health care spending.

 

Here”™s a word of advice for President Obama. Let”™s return to our original purpose and ask, “How can we provide universal health care?” One thing you can be sure of: it won”™t be one state at a time.

Georganne Chapin is president and CEO of Hudson Health Plan, a not-for-profit Medicaid managed care organization, and the Hudson Center for Health Equity & Quality, an independent not-for-profit that promotes universal access and quality in health care through streamlining. Both organizations are based in Tarrytown, N.Y.