With passage of historic health care reform in Congress, it’s easy to conclude that the final curtain on the saga of fixing the United States health care system has now fallen. But as long and contentious as the struggle to achieve federal reform has been, the theater we’ve witnessed so far is only act one, scene one. In this drama, center stage for health care reform now moves quickly to the legislative chambers of 50 states and the District of Columbia.
For many years now, major reforms to expand health care coverage, increase access, and address insurance abuses have taken place in state governments, sometimes described as legislative “laboratories of innovation.”
With federal health care reform leaving many disappointed (and others falsely assuming that America’s health care problems are now healed), continuing innovation on the state level is a reminder that the nearly century-long effort to treat universal access to health care as a human right—rather than a cash cow for corporate interests—is far from over.
States Take Charge
Following the passage of federal reform, a number of states have taken proactive steps to prepare themselves to implement—or improve upon—the legislation. California is moving bills to establish the legislature’s intent to implement federal health care reform. An Illinois bill to create a bipartisan Health Care Justice Implementation Task Force, with a goal of monitoring the fairness of the federal health care reforms has passed both the House and Senate. Across the country, states as diverse as Maine, Texas, Colorado, Oregon, Washington, Maryland, and Wisconsin have established commissions to examine their role in implementing federal reforms.
In Iowa, which already extends coverage to all children, a bipartisan bill to include an insurance exchange and expand the state's unofficial public option program to include adults with incomes below 200 percent of the federal poverty level was signed into law in April.
Even more impressively, both New Mexico and Colorado recently enacted laws to ban the insurance industry’s practice of charging women higher premiums than men (as much as 20 percent higher) for the same coverage. The State of Maine is now the first state in the country with a law that puts an end to annual and lifetime caps on coverage.
A History of State Leadership
In 2010, the spotlight turns to how the new law of the land will be implemented. Much of that huge responsibility falls on the shoulders of states, but their role as catalysts for change is anything but new.
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In the 1990s, the U.S. Congress struggled and failed in its attempt to pass a bill of rights for managed care patients. State leaders saw this vacuum of authority and took it upon themselves to make change: By 2001, no less than 46 states had found a way to pass these very popular reforms all on their own.
In 2006, Massachusetts paved the way for future reforms with the passage of a landmark law that sought to provide universal coverage for all residents; the Massachusetts model included an insurance exchange and individual mandates. That same year, the state of Vermont continued a long history of progressive reforms in health care with the creation of the Catamount Health Plan, which extended Medicaid coverage to residents with incomes up to 300 percent of the federal poverty level.
In 2009 alone—despite a deep economic recession and the imminent promise of national health care reform, either of which could have easily stalled state progress—41 states increased access to health insurance. Thirty passed private insurance laws that improved access, and 26 expanded eligibility for public programs. One 2009 highlight took place in Connecticut, where the state government enacted Sustinet, a comprehensive health care reform package with a goal of providing affordable health coverage to 98 percent of state residents by 2014.
While federal reform, in its final version, left much to be desired, many of its best aspects—including major expansions in coverage to the uninsured as well as regulations to end such insurance abuses as policy rescissions, premium increases, and exclusions due to pre-existing conditions—originated in state reforms.
State governments benefit from more flexibility, more direct awareness of the costs of health care, and less pressure from corporate interests than the federal government. As the show goes on, health care reform on the state level will continue to be a compelling force on the path toward true national reform.