"Health Week" in the U.S. Senate, just like the national "Cover the
Uninsured Week" also held in May, failed to result in any Senate
legislation to deal with the problems of uninsured Americans. And
in all probability, if any legislation is passed by the House next
week during its "Health Week," that legislation will be pushed
through on a party-line vote and will fail to be enacted by the
Senate. With the political gridlock on health care, neither side
has the votes in Washington to enact significant reform.
But a bipartisan
group of Members is taking a radically different approach to
achieving reform that could break out of the gridlock in a
refreshing way. Rather than trying to impose a national solution,
this approach would instead give strong encouragement to the states
to take the lead, allowing them to try proposals currently bottled
up in Congress and rewarding states that achieve the goal of
improved health care coverage. Successful welfare reform started in
the states, and state welfare reform initiatives were given an
enormous boost in the landmark 1996 federal legislation. This
approach applies the same strategy to health care.
A bill to move in
this direction was introduced in the Senate during its "Health
Week" by Senators George Voinovich (R-OH) and Jeff Bingaman (D-NM).
Meanwhile a bipartisan group of Representatives spanning the
political spectrum is developing legislation along very similar
lines. They are led by Reps. Tammy Baldwin (D-WI), Bob Beauprez
(R-CO), Tom Price (R-GA), and John Tierney (D-MA).
As the House
considers action on health care next week, lawmakers should look
carefully at the Senate bill and the emerging bipartisan House
proposal. Spurring states to experiment with competing approaches
to solve the nation's coverage problems, building on the
considerable state innovation already under way, is far more likely
to lead to real improvement than continued partisan bickering in
Voinovich-Bingaman "Health Partnership Act" (S. 2772):
- States would
propose initiatives to a bipartisan "State Health Innovation
Commission" housed within the U.S. Department of Health and Human
Services. The Commission's members would include governors, state
legislators, and county and city officials, as well as members
appointed by the Senate and House.
- The Commission
would review and approve a slate of proposed state initiatives.
According to the bill, the slate must include a broad variety of
proposals, such as initiatives based on health savings accounts
(HSAs), expansions of the State Children's Health Insurance Program
(SCHIP) or other public programs, health care tax credits, and
pooling arrangements like the Federal Employees Health Benefits
Program (FEHBP). To be considered, each proposal would have to
specify clear and measurable goals, including coverage increases
and quality improvements. Each proposal would also have to indicate
its projected net effect on federal revenues.
- The Commission
would send its slate of initiatives to Congress for expedited
("up-or-down") consideration. If Congress approves the slate, the
"toolbox" changes in federal law necessary for the proposal (such
as changes in SCHIP or expanded HSAs) would go into effect only
within the states proposing those federal-level changes in
conjunction with state-level steps - not over the whole
- States would
receive performance grants according to their success in reaching
the agreed federal-state goals. The states would have to provide
reports on performance, to be audited by the Commission, to qualify
for these grants.
- The initiatives
would be authorized for five years and could be renewed if
important reasons, the Senate bill, as well as the developing House
proposal, offers real hope of progress in covering the
- It recognizes
that creative solutions are more likely to be found at the state
level than in Washington. Successful policy is more likely to
emerge from continuous and competitive experimentation than from
trying to figure out the right answer within the Beltway and then
imposing it on the rest of the country. In state after state - most
recently in Massachusetts - governors and state legislatures are
launching initiatives that, whether they succeed or fail, will
prove instructive to us all and help America inch towards the goal
of adequate coverage for all.
- It understands
the best way Congress can foster state innovation. States will
be most creative if Congress sets broad goals, rather than
micromanaging state action. Congress can help most by removing
bureaucratic obstacles, making creative federal initiatives
available, and rewarding state successes in reaching agreed goals.
This facilitating role has been highly successful in welfare, where
the rolls have been cut by half since 1996.
- The "toolbox"
feature of the bipartisan approach means that conservative and
liberal proposals that are currently bottled up in Congress could
be tried in willing states. Currently, federal initiatives
proposed by a group of Members - typically with the support of
their state - do not get enacted because they would apply across
the nation and many other members oppose them for their own states.
By limiting these federal proposals to only those states wishing to
use them as part of their own proposals to the Commission,
opposition would be less intense. Moreover, sponsors of the
bipartisan approach envision a positive form of "logrolling" as a
feature to build support for a slate of proposals. A liberal
Member, say, would vote for a conservative Member's idea for that
Member's state in return for the conservative Member voting for the
liberal Member's idea in that Member's state. In this way, ideas
that cannot be enacted today could win congressional support for
limited and temporary application. And rival proposals would be
tested to see which really work.
- A commission
can build broad support in both parties and among the states.
The Commission included in the Voinovich-Bingaman bill and being
developed in the House proposal would draw together a wide and
bipartisan range of representatives from each level of the federal
system to evaluate applications from the states and develop a slate
for Congress to approve. Using a commission to pre-approve
initiatives would reduce concerns that the selected initiatives
would reflect the ideology of only one party or the goals of only
one level of government.
rewards to states would depend on performance.The legislation
would authorize the Secretary of Health and Human Services to
provide grants to participating states to offset the costs of their
initiatives. The allocation of the grants, however, would be linked
directly to measurable performance in reaching their initiatives'
goals. The grants would reward real outcomes, in other words, not
mere promises and projections.
Voinovich-Bingaman bill and the similar initiative developing in
the House would give a congressional green light to creative state
efforts to improve coverage while finding solutions to the many
costly problems of America's health care system. Under current
federal law, states are unduly restricted in their ability to find
better ways of covering their residents. This refreshing and
bipartisan approach, built on solid principles of federalism, would
give states the incentives and the policy tools they need to
achieve the nation's health coverage goal.
M. Butler, Ph.D., is Vice President for Domestic and Economic
Policy Studies at The Heritage Foundation