Health Reform Requires State And Federal Cooperation

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Main Category: Health Insurance / Medical Insurance
Also Included In: Medicare / Medicaid / SCHIP;  Public Health
Article Date: 22 Oct 2008 - 0:00 PDT

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It is necessary for states and the federal government to work collaboratively in order to achieve comprehensive health care reform, according to an article published in the October 22/29 issue of JAMA. Ezekiel Emanuel, M.D., Ph.D., (National Institutes of Health, Bethesda, Md.) and coauthor U.S. Senator Ron Wyden, J.D. write that states alone cannot overcome the barriers and challenges that preclude high-quality, affordable health care.

In 2006 Massachusetts passed a health reform bill that encouraged many other state legislatures to begin discussing the topic. However, not one state legislature was successful in enacting legislation that provided health care for all of a state's residents. "States cannot reform health care on their own," write Emanuel and Wyden. "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."

There are several challenging barriers that stand in the way of a state's unilateral implementation of significant health care changes:

• Changing federal tax laws related to health insurance
• Self-insured employer regulations set by ERISA (Employee Retirement Income Security Act)
• Modifications to Medicare and Medicaid
• Health coverage programs for federal employees in the state, the military, and veterans
• Costs of financing reform
• Costs of reforming the health care delivery system.

Except for Massachusetts' constantly evolving health reform bill, comprehensive reform efforts have failed in all other states that have tried.

Emanuel and Wyden call for states to act as facilitators, regulators, and innovators since it is clear that they cannot act alone in health care reform. "First, states should be facilitators by creating and overseeing insurance exchanges," write the authors. "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."

They add that, "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." The authors suggest that authority should be granted to states that will encourage the development of innovative programs that are customized to the needs of their citizens. They write that, "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," conclude the authors.

A New Federal-State Partnership in Health Care
Ezekiel Emanuel, MD, PhD; Ron Wyden, JD
JAMA (2008); 300[16]: pp. 1931-1934.
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Written by: Peter M Crosta
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