Where healthcare reform happens: the states

The healthcare debate is just that in Washington - debate. But beyond the nation's capital, there is plenty of action at the state level, where activist legislatures and grass-roots campaigns are changing healthcare delivery.

The efforts are scattered and disparate, but together they are chipping away at issues of healthcare cost and availability, and patients' rights - in some cases dramatically.

In recent weeks, for instance, Maine became the first state in the nation to enact a form of price controls on prescription drugs.

Arizona, Oklahoma, Washington, and Maine this spring have joined the lengthening list of states affording patients greater rights in relation to their health maintenance organizations (HMOs), in some cases including the right to sue.

In Massachusetts, activists hope to use a ballot initiative this fall to gain health-insurance coverage for everyone in the state by 2002.

Not every effort succeeds. A plan to grant health insurance to all children under 18 in the city of San Jose, Calif., was recently defeated. But even that example epitomizes the growing grass-roots fervor for health reform, say analysts, and the bottom up pressure it is applying on the political system.

"Our experience is that people are coming out of the woodwork and saying they're tired of waiting for Washington on healthcare," says Bob Brownstein, a lead activist on the failed San Jose effort.

While a prosperous economy and relatively restrained health costs kept the issue in check through much of the mid- and late-1990s, surging costs and a steady increase in the number of Americans without health insurance have changed the public mood.

"There seems to be a new insecurity out there," says Joel Miller, director of policy at the National Coalition on Health Care (NCHC) in Washington, and it is born of some ugly economic trend lines.

Health-insurance premiums are now rising at a pace unseen for a decade. Premiums are forecast to rise at four times the rate of inflation this year and for several years to come, an acceleration that is unprecedented in relation to inflation, says the NCHC.

Growing ranks of the uninsured

At the same time, even amid an economic boom that has record numbers of people working and corporations and governments swimming in black ink, the number of uninsured is growing by about 1 million people per year. That is on top of the estimated 46 million uninsured Americans today.

And with health-insurance premiums rising sharply, many experts expect the number of uninsured to grow even faster in the years ahead.

After the Clinton administration's early healthcare-reform push failed, the public has sensed a sort of "void" on the issue, says Mr. Miller. Now, with consumers feeling the brunt of higher costs, some alarm bells are going off.

While economic pressures are motivating much of the activity, economic benefits are playing a role too.

The landmark tobacco settlement of 1998 will send more than $200 billion in new revenue to 46 states over the next 25 years, with many states eager to use those funds for health-related issues.

"The tobacco-settlement funds have stimulated creative thinking in healthcare," says Richard Cauchi of the National Conference of State Legislatures.

That money has begun flowing this year, allowing a number of state legislatures to commit new dollars to longstanding needs. One of the greatest beneficiaries so far has been a range of state programs aimed at keeping a lid on the costs of prescription drugs, particularly for seniors. At least a dozen states, says Mr. Cauchi, have taken steps to lower prescription-drug costs this year.

That same issue is being hotly debated in Congress. Specifically, the issue is how or whether to add prescription-drug benefits to Medicare coverage for the elderly and disabled, and how to pay for it.

A partisan 'wedge' issue?

But in an election year, many analysts worry that each party is more concerned with scoring political points than with enacting healthcare legislation.

President Clinton turned up the heat last week, criticizing an expected Republican version of his Medicare plan by calling it a "fraud."

Congress is also hotly debating a patient's bill of rights, which right now is in a legislative conference committee.

"The states are moving on an issue that seems stalled in Congress," says Mr. Cauchi, though there are also innovations at the state level that have nothing to do with the national debate.

For instance, a portable machine to help victims of cardiac arrest has long been subject to severe restrictions in most states, which worried about improper use and lawsuits. But now some 45 states have taken steps to encourage the machine's use by lay people, says Cauchi.

One issue not being seriously debated in Congress is the notion of universal coverage for all Americans. But many analysts expect the issue to rise in importance this fall if it makes it onto the ballot in Massachusetts, as expected.

(c) Copyright 2000. The Christian Science Publishing Society