States Are Future of Healthcare Reform.

The federal government may be gridlocked on healthcare reform, but the states are poised to take bold, bipartisan steps in healthcare policy, writes David Jones, assistant professor of health law, policy & management, in a new New England Journal of Medicine editorial.

“Shared understanding of the problems and goals may create opportunities for bipartisan collaboration, policy innovation, and difficult conversations about the role of government—if state officials are willing to take risks,” write Jones, Christina Pagel of University College London, and Christopher F. Koller of the Milbank Memorial Fund. “Then … their efforts will show the way for that lagging legislature in the District of Columbia.”

Jones, Pagel, and Koller reached out to state leaders to discover how they view the current landscape, and to identify potential paths to consensus. First, the authors sent out a nationwide survey asking all state legislators serving on committees related to health to rank their policy priorities. The authors then went to Colorado and Kansas to have conversations with legislators, executive-branch leaders, and key stakeholders about the survey results.

Leaders expressed frustration with “a dysfunctional and chaotic environment in Washington,” the authors write. Access to health care was a top priority on all sides, with leaders expressing particular concern about health care in rural areas. “Nearly enough Republicans in Kansas supported Medicaid expansion to override a veto from fellow Republican Governor Sam Brownback because they believed it would help their rural hospitals stay open,” the authors write.

Jones and his co-authors identify healthcare costs as the greatest opportunity for bipartisanship, based on their survey, but also note that their interviews in Colorado and Kansas revealed little agreement on the root of the issue, or on whether costs to government, consumers, hospitals, or providers should be prioritized. “Policymakers are likely to continue talking past each other until a common language is developed to differentiate various types of costs,” they write.

A point everyone seemed to be able to agree on, the authors write, is that philosophical differences over the role of government pose the greatest threat to state healthcare reform. The authors found that members of both parties try to bridge this divide by framing health policy conversations in terms of how the public sector can get the most value for what it spends. “Similarly, people on all sides expressed a desire to expand the scope of the conversation beyond insurance and medical care to the social factors that shape health, such as housing and employment, and to look at the proper role of government in that context,” they write. “Divisions softened—even among staunch conservatives in Kansas—as the focus shifted from health care to health more broadly.”

While there are certainly dangers to the way that states are currently going in radically different directions on healthcare policy, including the risk of exacerbating inequities, the authors write that the current period of state-level experimentation will provide valuable lessons on what strategies are effective. Policymakers, stakeholders, and academics would do well to pay attention and gather data on these experiments, they write, and to use these lessons to facilitate bipartisan cooperation across the country.

In a BMJ podcast accompanying the editorial, Jones reflects on how the results of the 2018 midterm elections will affect state-level action on health reform. Voters showed that health reform is a top priority, Jones says, and gave Democrats control of governorships in several states. “It’s going to be fascinating to see how this plays out over the next few years.”

—Michelle Samuels