The passage and ongoing implementation of the Massachusetts Health Reform law has sparked interest among governors and legislators across the country in finding ways to expand access to affordable, high quality health care. It seems, in fact, that there is a growing political consensus that reforming the health care system should be a major national priority. Despite the growing recognition of the pressing need for health care reform, consensus on how to go about reforming the health care system has been elusive at the federal level. If history is any guide, this will become even more challenging in the coming election year.

As we approach the presidential elections in 2008, every presidential candidate is being pressed to present their detailed plans for health care reform. Not surprisingly, many of these plans view “fixing the system” from a national vantage point. However, our health care system is an amalgamation of different component delivery mechanisms with varying levels of quality and efficiency in delivery and practice. While some major aspects of heath care are truly national in scope, the reality of our health care system is that health care delivery is truly local.

In this regard, it is not surprising that some states and local communities are leading the way to health care reform through innovation in coverage expansion and by enabling and promoting greater quality and cost savings in health care. California, Connecticut, Maine, Indiana, New Hampshire, New York, Vermont, Wisconsin and Massachusetts, are notable examples of states that are already exercising leadership in this area. However, there is the potential that state leadership and innovation in health care could easily get lost in the clamor for “national solutions”, particularly in an election year.

Many state health care reform efforts have emphasized coverage expansion for low to medium income citizens. While this is an important aspect of state health reform, expansion of health care coverage without consideration of maximizing efficiencies and improving quality will only raise costs and further exacerbate the health care financing crisis. In the coming months, state legislative leaders need to work with health quality experts at the national level to integrate national efforts and progress on improving quality into state efforts and to simultaneously recognize and leverage the breakthrough progress in quality improvement that is being made in the states.

As a starting point, the National Conference of State Legislatures, and other policy groups hope to conduct a thorough review of the common characteristics of successful approaches to state health care reform. Common elements of success will serve as a useful “learning” for other states and national leaders in considering more comprehensive health care reform. This may also generate a consensus among state policy makers about how the federal government can be helpful to states in encouraging health care reform.

We need to understand how some federal policies could or should be changed to allow greater flexibility for more meaningful reform at the state level. Through this process, it is hoped that a limited set of “doable” reforms could be identified that hold the most promise for supporting coverage expansion. A focus on innovative approaches to coverage and financing along with a thorough examination of quality improvement opportunities can achieve the goal of improving the quality of health care at an affordable cost.

Federal reimbursement policies, for example, that fail to give incentives for physicians to enter or remain in primary care have led to a shortage of primary care physicians. Yet, expanding access to insurance, and thereby, to care is also a goal of federal policies. However, if there are not enough primary care physicians or health centers with primary care doctors, people will still not be getting the preventive care and screening needed to reduce emergency department usage and cost.

In addition, in our effort to expand efforts to improve quality and safety in health care, we need to examine the current misalignment of payment systems. For example, if a hospital puts resources behind an effort to reduce medical errors, the insurance plans or individual patients receive the benefit of reduced cost. We need to establish a mechanism where the cost for quality and safety initiatives, as well as any savings, is shared by the provider and the payer. Other federal policies, such as ERISA, limit the ability of states to expand access to care through employer-based insurance, and we should consider if changes can be made to give greater flexibility to state governments.

Most observers believe that, regardless of which candidate or party controls the White House or the Congress, major national health care reform will take time. As health costs escalate annually, we need to focus on what works, as demonstrated in the states. As legislators in Iowa are now doing, we need to ask presidential candidates what they will do to support state efforts at health care reform and to avoid federal policies that impose costly mandates or burdensome regulations that make health reform more difficult.

Senator Richard T. Moore
Senate chair of the Joint Committee on Health Care Financing