Collaboration Between States, Federal Government Key To Health Care Reform

Ezekiel Emanuel, M.D., Ph.D., of the National Institutes of Health, Bethesda, Md., presented the commentary at a JAMA media briefing at the National Press Club in Washington, D.C.

Dr. Emanuel and co-author U.S. Senator Ron Wyden, J.D., write that when Massachusetts passed a health reform bill in 2006, numerous state legislatures met and sought to enact legislation providing health care for all state residents, but not one was successful. "States cannot reform health care on their own. Governors and state legislators, in concert with federal officials, must reconceive federal-state health care relations so that together they can meet the health care needs of all Americans."

The barriers to states implementing substantial health care changes on their own are substantial. They include programs and factors out of states' control: changing federal tax laws related to health insurance, self-insured employers regulated by ERISA (Employee Retirement Income Security Act), modifying Medicare and Medicaid, and the health coverage programs for federal employees in the state, the military, and veterans. Other barriers to state reform are the substantial costs with financing reform and reforming the health care delivery system. In fact, excluding Massachusetts' health reform bill, which is still in evolution, every time states have enacted a comprehensive reform effort it has failed.

Although states cannot make the changes alone, they can play three critical roles in health care reform. They can be facilitators, regulators, and innovators, the authors write. "First, states should be facilitators by creating and overseeing insurance exchanges. They are the logical place to develop insurance exchanges, manage enrollment, help state residents choose from a variety of plans to meet their needs, and provide informational materials to consumers and employers. In a new federal-state health partnership, the states should serve as the point of contact for self-employed individuals, workers in small businesses, and those who would be part of a reformed individual market."

"Second, states should be important regulators. The logical place to regulate health insurance plans is at the state level. States oversee these plans today through insurance commissioners in each state. They should continue to protect consumers in a new federal-state health partnership, ensuring that plans sold in the state prohibit discrimination against individuals with preexisting illnesses, provide for fair marketing practices, and oversee grievances and appeals. States should oversee the development of standardized common claim forms and uniform billing practices to reduce administrative waste."

"Third, states should be important innovators," they write. "… states should be granted a broad waiver authority to develop innovative programs tailored to meet the unique needs of their citizens. In addition, neither the federal government nor business has taken sufficient initiative regarding wellness and prevention programs. States can develop novel programs around wellness and prevention that focus on the entire state population. … Plans could also push for the development of more effective uses of health information technologies. States could require insurance plans that enroll state workers to open electronic medical records for them at the expense of the private insurer."

"The American public wants what only the federal government can guarantee—that all Americans, regardless of where they reside or work or any other characteristic, have high-quality, affordable health care. It is impossible to have one level of government oversee all aspects of health care for 300 million Americans. States will and should have a role in any comprehensive health care reform, but they cannot do it alone. The federal government will have to take initiative to achieve sustainable and successful reform," the authors conclude.