Why State Policy Precedes National Reforms
Maggie below echoes Ezra Klein's worry that failures at the state level on health reform will undercut national reform, but I think its a larger worry that too large focus on federal changes-- that will almost certainly be filibustered -- will draw energy away from and undercut the more likely-to-succeed state efforts. The flameout of the Clinton plan did suck the life out of many state efforts. As I've said, I think short-term state reforms and long-term organizing at the national level can go hand-in-hand, but I think the danger of overhyping efforts that fail at the federal level is a far greater danger to state efforts than vise versa.
And Maggie touched on a favorite point of mine when she compared the fight for national health care to the civil rights effort, since passage of the national Civil Rights Laws were preceded by many states passing state civil rights laws. Frustrated by the failure of the federal government to pass anti-lynching and other civil rights laws, the states began moving on civil rights laws.
The first law banning discrimination in hiring practices was passed by New York State in 1945 and was followed by states and cities across the country passing civil rights laws. Hubert Humphrey became a national political leader on civil rights based on his role as mayor in passing a city civil rights law in Minneapolis. In fact, it was efforts by states to protect voting rights IN THE NORTH that forced national politicians in the 1950s to begin seriously campaigning for civil rights at a national level.
Federal civil rights laws were the product of twenty years of state and local civil rights laws being passed and implemented. They created an irrestistable argument that if other states could pass civil rights laws, then a national civil rights law was needed to protect blacks in the remaining southern states that refused to protect their citizens from discrimination.
Similarly, state-based health care programs will increase the demand that the uninsured in states without such programs gain the protection of a national health care plan. Maggie may be right that individual states don't have the same buying power to take on the health insurance companies as the feds, but they do have the ability to form interstate-compacts and interstate-purchasing pools to increase their purchasing clout. In fact, such pools are forming for prescription drugs and a few other health care areas, and a state-by-state program of integrating state programs could become the nucleus of a national health care program, all preceding any national vote.
Whether we are talking about labor legislation, environmental regulations, and civil rights, there is almost no example of serious national reform happening before such reforms have been enacted in states around the country. Health care reform is not likely to follow a different pattern, since the structural limits of national reform due to the archaic structure of the Senate has been a constate obstacle to progressive change throughout our nation's history.
Part of the dynamic is that state programs become models for federal action, but the other dynamic is that different state reform efforts push businesses to start demanding national laws, not because they actually want the reform, but because they prefer more uniform national rules to a patchword of state laws. But without the creation of the state laws in the first place, the pressure on business to accept change -- and stop using the filibuster to defeat national reform -- just doesn't exist.
Politically, state healthcare reforms might work as a sort of farm system that will, over time permeate the federal government with people who believe in universal, national coverage.
A state governor succeeds. Uses that success to gain national office, either by election or appointment and then they'll try to recreate their successes on a national level.
It'd take time but could work. A lot of governors could turn themselves into national stars by getting something done in spite of the federal government.
thosethingswesay.blogspot.com
July 13, 2007 8:57 AM | Reply | Permalink
Some of you very smart folks are forgetting that 1993-1994 IS N0T 2009-2010
In amost 15 years the US health care crises has gotten MUCH worse and the US electorate MUCH more restless.Even big business is pissed.
THE FEDS WILL INDEED PASS LEGISLATION IN 2009-2010
Dr. Rick Lippin
http://medicalcrises.blogspot.co
July 13, 2007 9:17 AM | Reply | Permalink
Nathan -
Norman Vincent Peale - "The Power of Positive Thinking."
It's a classic.
July 13, 2007 1:33 PM | Reply | Permalink
Nathan-
First, I definitely respect the work that reformers are doing in the states.
Part of what makes health care reform difficult is that it's so complicated. There is no one villain that you can point to in order to describe what is wrong with our health care system. Private insures, drug-makeres, device-makers, some hospitals, some specialists and patients themselves are part of the problem.
Michael Moore does a nice job of taking on private insurers--though he confuses the issue a bit when he suggests that the insurer should have paid for a bone marrow transplant for a dying patient. The fact is that, at that stage of that particular disease, it's not credible that the transplant would have done good.
Part of the problem with our profit-driven system is that we often waste money on things that do people no good while failing to given proven care to people who need it.
Explaining all of this to the public will I think, take more than a year or two. The more people who are talking honestly and seriously about the problems--and truly educating the public--the sooner we will get there. In this way, state reformers can help.
I am, however, concerned about governors or state legislators who may simplify the problem and then pretend that they have "solved it" --by requiring all employerse, large and small, to pay into a fund,for example, or by requiring all citizens to buy insurance, or by mandating a bare bones "basic" plan for everyone and telling the state's citizens that they are now covered.
For reasons that I won't go into here, I am not impressed with any of plans that states are currently proposing. In various ways, they're ignoring problems, or trying to take short-cuts. I am more impressed by Edwards, Obama's and what we have seen of Clinton's plan. They are more detailed and are much more aggressive in taking on insurers, drugmakers etc.
Meanwhile, the promise of quick solutions at the state level could only confuse the public.( Critics of "solutions" that are really "sell-outs" will have to try to
explain what's wrong with a dozen or two dozen different plans--and they will all problematic in different ways. )
The fact is that there is no easy solution.
Health care just won't be affordable until we stop paying twice as much for everything than any other country in the world. This means insisting on very steep discounts from drug-maker and device-makers; this means paying family doctors more for preventive care and paying specialists who make $750,000 a million or more less.
This means telling communities that they can't build a new hospital with a waterfall in the lobby because they really don't need more hospital beds. (This is not something that state legislators will be eager to do.) This means telling communities that they don't need another MRI unit--and telling patients, that, in many cases, they don't need an MRI. This means telling hospitals that they are going to have to take down walls and turn their private rooms into rooms for two or three patients. (Most of the many hospitals being built now are nearly all private rooms. Who is going to pay for that?)
As for states banding together to solve problems-- even if two or three states unite they will not have the clout to deal with private insurers or Big Pharma.
In California, even CalPers doesn't have the clout it needs to negotiate reasonable prices from California's hospitals.
The only entity that has the muscle to deal with the for-profit healthcare industry is the VA-, the largest healthcare provider in the country. And note that the VA's widely-admired reform happened at the federal level. At took a combination of a crisis in the VA system--and very strong person at the top to make it happened, but it happened. The VA is arguably the best model for what we want nationwide.
AS to how healthcare reform is different from states passing civil rights laws, environmental controls, etc: In those other areas legislation could be passed at the state level that didn't require the state to come up with funding. Healthcare reform requires money.
And unlike the federal govt. states are not allowed to run deficits--which means that they don't have deep pockets. In economic downturns, state programs suffer. (This is part of what went wrong in Oregon-- even though Kitzhaber was a deeply committed, extremely knowledgable reformer. And this also explains why Medicaid and Schip have been such poor programs for the poor--it's up to the states whether or not they want to fully fund the programs. )
To achieve sustainable health reform, you
need the deep pockets the Federal govt has --and the power it has to break the healthcare cartel that is forcing us to overpay for every aspect of health care.
Finally, I am concerned that, insofar as the states are not in a position to finance and enforce sustainable, affordable, high quality healthcare, conservatives will use their failures as evidence that it can't be done.
.
July 13, 2007 2:25 PM | Reply | Permalink
"This means telling hospitals that they are going to have to take down walls and turn their private rooms into rooms for two or three patients."
I have to disagree strongly with this idea though I could accept people paying a bit more for a private room. My sister was hospitalized frequently with a chronic illness that was ultimately fatal and there were a few times she had to share a room with some really scary patients. You are not going to get middle class patients to accept being in the same room with some very hostile, foul mouthed, and out of control types who will steal them blind if they have half the chance. You just aren't. That alone could kill a government plan. And this from a leftie like me!
Whatever plan we adopt cannot work making the middle class obviously worse off than they are now.
July 13, 2007 3:42 PM | Reply | Permalink
Re: This means telling hospitals that they are going to have to take down walls and turn their private rooms into rooms for two or three patients.
Seems to me that doing this would be counterproductive. The hospital is already built. You're not going to save money by changing the rooms now; instead it's going cost money. Of course when future hospitals are built you might look at saving money that way, though I'm not convinced that there would be significant savings there. I've seen in single patient rooms and dual patient rooms. The latter tend to be twice as big as the former so there's no real economy of scale there.
July 13, 2007 3:45 PM | Reply | Permalink
I wouldn't assume that private rooms are necessarily an inappropriate expense. Before making such an assumption, it is worth looking at several metrics.
There is increasing evidence that private rooms reduce hospital-acquired infections. Sometimes, this may be for reasons as simple as staff being conditioned to handwash on entering or leaving, and not being tempted to do something for another patient without intermediate handwashing. Another factor may be accidental confusion of contaminated items being returned to the wrong patient.
Private rooms may reduce length of stay. Jokes about awakening a patient to give them a sleeping pill aren't always accurate, because sleep is a major part of recovery. Hospitals are amazingly noisy, even in private rooms. Television, even with pillow speakers, can add noise. If one patient has far more visitors, or specialized in-room treatment, than another, the other patient may not get adequate rest.
Recognizing that the singular of data is not anecdote, I will observe that in my last two hospitalizations when I did not have a private room, I had a delirious roommate, and, in one case following open-heart surgery, one that scared the hell out of me as being potentially dangerous. It was a nasty judgment call, but I felt unsafe in hitting the intercom while my roommate was throwing things and threatening; I grabbed my IV pole, dragged myself out of bed, and staggered to the nursing station, luckily a few steps away.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 13, 2007 9:28 PM | Reply | Permalink
I agree. Hospitals have too few nurses to cope with these problems. It may seem fine to the physician who shows up for 10 minutes but for the patient trying to survive their chaotic roommate, it's pure hell.
July 14, 2007 9:12 AM | Reply | Permalink
Bluebell--
I completely agree that under certain circumstances middle-class people will want a private room and will be willing to pay for it if their insurance doesn't cover it (which it often doesn't.)
But in other cases--when people are not in great pain or dying, they may appreciate the company. I was in a double room after I had each of my children, and that was fine.
Children who are sick (but not dying) often appreciate being with other children.
My husband has had elective surgery for a number of "sports injuries" and while he was an outpatient, he would recuperate in a large room with other patients and not mind at all.
It sounds like you had a couple of terrible experices at a painful time, and I sympathize. Obviously if someone is dying the person and his or her family want privacy. And of course disruptive patients shouldn't be put in rooms with quiet patients --maybe they could be paired with other disruptive patients?
July 14, 2007 2:07 PM | Reply | Permalink
"My husband has had elective surgery for a number of "sports injuries" and while he was an outpatient, he would recuperate in a large room with other patients and not mind at all."
My 86 year old mother had cataract surgery in a similar situation but I had to wonder at how they had her virtually shouting out her personal information in a clinic designed so that anyone could hear! So much for HIPAA.
I'd think there could be improvements in hospital and clinic design that might inprove privacy. I would hope we'd devote some research funding to how to deliver patient centered care.
July 14, 2007 2:54 PM | Reply | Permalink
Maggie,
Please examine some of the work on nosocomial infections that suggests the larger the room population, the higher the risk. Hospital-acquired infection is a major concern, and dealing with it is going to mean doing away with quite a few hallowed customs. Culture the water from a vase of cut flowers, and, much of the time, there will be a high concentration of Pseudomonas. Burn units and most ICUs have banned flowers, and I believe this is a necessary trend.
From Barclay L, "Improvements Needed in Infection Control, Survey Suggests", Medscape Medical News
More and more patients are immunosuppressed, and at risk for organisms such as Aspergillus. Patients are not routinely screened for tuberculosis before assignment to rooms.
From Noskin GA "Engineering Infection Control through Facility Design",Emerging Infectious Diseases7(2), 2001:
What happens when a disruptive patient turns disruptive in the middle of the night?
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
July 14, 2007 3:23 PM | Reply | Permalink
Health Care for the low end of the economic spectrum is a difficult and a vitally important issue. It is even more difficult when the debate goes off track, or becomes anecdotal, both of which clearly have happened here.
As for the issue of State vs. Federal, Nathan has one particularly strong point: getting something done at the state level is better than failing to get something done at the federal. His parallel with the Civil Rights movement is faulty, however, in at least one enormously important particular. The attempt to legislate civil rights began, in earnest, around 1865. While it was a Federal initiative, most of the legislation involved forcing the states to give African-Americans "equal" rights before the law and then letting state legislatures work out the further legislative details themselves. It is an established fact of history that leaving Reconstruction to the states was the same thing as abandoning southern (and, to a lesser degree, northern) blacks to their fate.
Reconstruction lost the last vestiges of its federal aspect as the business-wing of the Republican Party wrested the bloody shirt from the radical-wing and put it to its own purposes. During the 30 years that followed, the southern states undertook a race to the bottom, in the end leaving African-Americans only the semblance of citizenship (and not even much of that) for more than half a century.
During that half century, leaving "the color problem" a state issue was absolutely essential in order to prevent civil rights in the southern states. In those states African-Americans "had their freedom," it should be recalled (just as the impoverished citizens of the states will "have their health coverage"). Their "betters" just kept them on a short leash in order to assure that they didn't misuse it.
Legislating huge national social problems state by state can be a desperately long and divisive process, at one moment "on a track to succeed," at the next little more than an illusion constructed to advantage the more advantaged citizens of the state.
The argument that civil rights for African-Americans involved an irrational hatred not in evidence in the health care issue is not as strong as it might seem to be to some. Black slavery and disenfrancisement, in the halls of state legislatures, were based upon economic issues and maintenance of power: the same factors that will decided the details of state health care legislation.
Favorable programs (from the Progressive point of view) will tend to convince businesses to establish plants in other states that have been "more realistic" and will tend to attract higher numbers of low-skilled workers to the state to take advantage of the "more realistic" plan. In the states with more favorable programs (programs offering legitimate coverage for which the employer pays the lion's share) fewer small businesses are likely to be started. More are likely to close their doors.
These tendencies will place stress upon the given state budget, especially during difficult economic times. The budget-item for the health care plan will be vulnerable, the recipients having little effective representation, and it may be impossible to choose to do anything else but to increase the share of the costs that the mandate will place upon the individual and/or reduce the mandated level of coverage. In the end the laws will amount to a mandate that the poor buy a third rate product that does little more than enhance the profit structure of the state's hospitals and insurance industry.
July 15, 2007 4:51 PM | Reply | Permalink
My bad. I slipped off track in the last paragraph of my previous comment. I had referred throughout to the type of plan in which employer and employee share the cost of the health plan. In the final paragraph, however, I explained, in very general terms, the mechanism that reduces the quality of a plan paid for from out of general tax revenues:
In an employer-employee plan, the same pressures would be brought to bear during difficult economic times. The tendency would be to reduce employer share of mandated insurance as part of an attempt to increase the rate of business growth and subsequent tax revenues such that the state's budget situation would be improved.
July 15, 2007 6:32 PM | Reply | Permalink