diverse and bipartisan group of House Members has introduced
legislation that would give states a green light to take bold
action on tackling the problem of the millions of Americans without
health insurance. Under the "Health Care Partnership Through
Creative Federalism Act" (), states could propose to a commission a wide range
of approaches incorporating state action, federal grants, and
changes in federal programs and laws that would achieve savings and
reprogram money to improve coverage. The commission would then
select a set of proposals and submit them to Congress for expedited
("fast-track") consideration. In this way, the legislation would
spur state initiatives to improve health coverage and access and
test the effectiveness of alternative reforms.
Representatives Tammy Baldwin (D-WI), Tom Price (R-GA), John
Tierney (D-MA), and Bob Beauprez (R-CO), H.R. 5864 represents the
decision of an ideologically diverse group of Members to break free
of the partisan deadlock that has thwarted most congressional
action on health care. It does this in two ways. First, it would
give the states the central role in proposing practical ways to
move forward, including necessary federal action. And second,
instead of promoting a single "magic bullet," the legislation
explicitly encourages a broad range of approaches, including
initiatives that would appeal to both conservatives and liberals,
so that rival approaches can be tested and compared.
legislation follows a bill () recently introduced in the Senate
by Senators George Voinovich (R-OH) and Jeff Bingaman (D-NM).
Commission: H.R. 5864 establishes a commission to review and
then recommend a slate of state proposals for congressional
consideration. The commission would have 19 members: the Secretary
of Health and Human Services, governors, state legislators, county
officials, mayors, and several members appointed by the House and
Senate (from both the majority and minority parties).
Proposals: State submissions to the commission would cover a
period of five years. These proposals could be statewide,
multi-state, or limited to sub-state regions. To be eligible for
consideration, proposals would have to contain a plan and
commitment to reduce uninsurance. Specifically, a state would have
to provide information on the manner in which it plans to expand
coverage; estimate the number and percentage of currently uninsured
that would receive coverage under the plan; describe the type of
coverage that would be provided; indicate how existing federal,
state, local, and private systems would be altered and coordinated
with the state plan; and describe planned efforts to expand access
to medically underserved populations. The state proposals could
contain federal legislative waivers, meaning that the initiative
might require changes in federal programs or laws that would apply
within the area covered by the state initiative.
of Proposals: States could propose a variety of ways to
provide coverage in order to reduce uninsurance. The bill does not
limit their options.
- Plan Cost
Estimates and Funding: State plans would have to include cost
estimates, such as expected public/private financing mechanisms;
federal, state, and local expenditures; anticipated costs to
businesses and individuals; and means for financial solvency.
Funding for federal grants would be determined by congressional
appropriation. But the bill also contains a budget neutrality
provision that requires initiatives to have no combined net cost to
the federal government beyond the grant program during the
five-year period during which state proposals would be
- Plan Review
Process: Upon receipt of a state plan, the commission would
review and negotiate with states individually and could ask for
more information. A proposal would need a two-thirds vote by the
commission to make the slate of proposals submitted to
Congressional Consideration: The commission would submit a list
of state proposals to both the House and Senate. The list of
proposals would receive expedited consideration in both chambers,
and the proposals could not be amended.
and Reports: States would be required to submit annual progress
reports to the commission. In turn, the commission would submit
annual reports to Congress containing recommendations. Finally, one
year prior to the end of the five-year experiment, the commission
would submit a report to Congress that evaluates the state projects
and may make recommendations for future federal action.
legislation would permit a wide range of state health care
initiatives, from consumer-based approaches centered on health
savings accounts to expansions of traditional government programs.
The bottom line for states would be measurable outcomes. The
federal government would offer a limited grant program as a reward
for innovation. States could propose creative approaches that
affect federal tax revenues or expenditures in many ways, but
beyond the appropriation for the grants, the net impact on the
federal deficit would have to be zero.
The way to break the deadlock in Congress over
health care reform-a partisan deadlock in which most ideas remain
bottled up-is to allow a diverse range of ideas to be tried and
compared systematically at the state level. The
Baldwin-Price approach recognizes that solutions to the problem of
uninsurance are far more likely to be found in state capitals than
in Washington. It builds on the momentum already seen at the state
level and gives encouragement not by trying to micromanage states
but by removing federal obstacles to innovation and rewarding
Stuart M. Butler,
Ph.D., is Vice President for Domestic and Economic Policy
Studies, and Nina Owcharenko is
Senior Policy Analyst in the Center for Health Policy Studies, at
The Heritage Foundation.