From the earliest proposal for health-care reform in the United States, the role of individual states has been a controversial topic.
In 1854, Dorothea Dix, a driving force for improving care for the mentally ill, pressured Congress to address the need for asylums. She proposed that Congress establish a program of federal land grants to individual states for the establishment of mental hospitals.
The measure passed both houses of Congress, but President Franklin Pierce vetoed the measure. He argued that the federal government had no role in social-welfare legislation, which he deemed the responsibility of each state.
This position is still being debated today.
In 1931, Oklahoma became the site of the first state-based, health reform program. Physician Michael Shadid challenged state authority when he established a clinic and hospital in Elk City for farmers and their families. The enterprise was chartered as a cooperative -- a consumer owned venture.
The American Medical Association and its state affiliate argued that the cooperative was illegal. The medical licensure board attempted to cancel Dr. Shadid's license to practice. After a heated battle, the legislature responded to pressure from farmers and approved the cooperative.
The Farmers Union Co-op provided care for 15,000 patients for years thereafter. Dr. Shadid encountered little opposition when he later helped found the much larger Group Health Cooperative in Washington State.
Enactment of Medicaid in 1965 gave individual states a major role in determining eligibility and benefits for poor residents. Some states, including Tennessee, have maintained eligibility for working adults at or above 100 percent of the Federal poverty level or FPL. Alabama currently sets its threshold at 24 percent of FPL, Georgia at 24 percent, and Arkansas at 17 percent. Florida's threshold is 58 per cent. Texas, with the nation's highest rate of uninsured residents, has a threshold of 26 percent.
Some states have maintained a broad range of services including mental health and dental care. Other states have offered a limited menu of benefits from Medicaid's outset. Rising health care costs and a slowed economy have led many states to reduce benefits, sometimes drastically.
States have experimented with different tactics to control Medicaid costs. Oregon recently established with bipartisan support a system of "coordinated care organizations" based in each city. The goal is a linkage of all health care providers electronically to achieve the most cost-effective care. Under the plan, case managers are assigned to chronically ill patients to improve outpatient care and thereby limit needless and expensive hospitalizations. Providers will receive bonuses based upon improved clinical outcomes and monetary savings.
The Supreme Court ruling of July 5 on the Affordable Care Act struck down a key provision to expand Medicaid uniformly across all states. Instead, each state will remain free to determine both eligibility and content of its program. As a consequence, we will continue to have wide disparities in health services and outcomes among the states for low income residents.
Beyond Medicaid, Massachusetts has devised the most ambitious health care reform model. The Massachusetts Health Plan, which Governor Mitt Romney signed into law in 2006 served as a model for the Accountable Care Act of 2010. It features an individual mandate for purchasing health insurance, standardized protocols for health insurance companies and mechanisms to control costs.
Since the passage of the plan, the percent of uninsured residents in Massachusetts has fallen below 2 percent, compared with 16 percent of Americans and 25 percent of Texans. The rate of increase in health care costs has dipped below the national average. The plan enjoys broad support.
Vermont, by contrast, plans a single payer system for health care of its residents.
As the tug of war between Federal and state powers continues, we must assure just standards for access, affordability, and efficiency. Establishing uniform standards for health care across state boundaries is the proper responsibility of the Federal government.
Contact Clif Cleaveland at cleaveland1000@comcast.net.