Two commentaries on "fact or fiction?" (Part II).

• Author: Riley, Trish
• Position: A discussion of health care reform issues in Canada and the U.S.

Ms. Riley is Executive Director, National Academy for State Health Care Policy, a non-profit forum consisting of health policy leaders from the executive and legislative branches of U.S. state governments.

In [another essay] laying out options for health care reform in the United States, Ted Marmor has proposed as one alternative a possible Federalist approach. I would like to build on this point and discuss a state-based strategy for health care reform. In fact, as Dr. Marmor points out, Canada began its health reform in one province-Saskatchewan-- and did so incrementally. The plan first covered hospitals for everyone and grew to broader coverage. As Dr. Marmor points out, we have taken a different approach in this country. Today only the elderly have universal access to coverage through Medicare, so I want to discuss the broader population of Americans without any health insurance. Indeed, there are more uninsured in the United States than Canada has citizens. About 140,000 of us in Maine below the age of 65 lack coverage. The biggest groups of uninsured are those between 18 and 24, often identified as the invincible-- individuals who think health coverage is not essential because they won't get sick-- and t hose between 60 and 64. This latter group often includes older Americans who were forced by illness or disability to leave the work force, have exhausted their COBRA extensions, and are left uninsured until Medicare becomes available.

While the notion of a national response and a national solution to this growing a absence of health insurance is appealing, Americans tend to be raging incrementalists. In fact, states can and must lead, particularly now that the U.S. Medicaid program is, in fact, larger than the American Medicare program in both dollars spent and numbers served. Indeed, states have a proud tradition of leadership and Congress has only acted in health reform after the states have served as laboratories for innovation. The Health Insurance Portability Accountability Act (HIPAA) provided protection, assuring that those who once had insurance will never lose that coverage even if changing jobs or becoming unemployed. While HIPAA does not deal with affordability, it was a major step forward in assuring the availability of health coverage for those who were once covered. HIPAA was enacted by the Congress only after the majority of states had passed similar health insurance reform initiatives. The Congress only enacted the State Ch ildren's Health Insurance Program (CHIP), covering all children up to 200 percent of the federal poverty level, after 26 states had experimented with similar programs of their own. Likewise, states have enacted patients' bills of rights, prescription drug reform, and initiatives to cover the uninsured--all of which the Congress is now negotiating and discussing. There is a clear track record for states taking the lead that Congress can follow. Regrettably, the issue of coverage for the uninsured is a costly endeavor and states will need federal dollars. But the State Children's Health Insurance Program (CHIP) is a model. Congress nationalized an effective state-based initiative by providing matching funds to states.

A reform for states will need to take a systems approach dealing with cost, quality, and accountability, and Norm Ledwin [CEO of Eastern Maine Healthcare] identified those serious tripartite issues in his opening remarks. America's resistance to health reform is difficult to comprehend. Certainly, part of the problem is the enormity of change in the deeply-rooted, complex system that cuts across multiple payers today. But...