Health insurance expansion through states in a pluralistic system

The United States continues to stand almost alone among developed nations i n its lack of universal health care coverage. In this essay, we argue that even though the debate over whether the federal government or states should lead the effort to expand health care coverage under the federal system is relevant in strategizing how to cover the uninsured; the more critical iss ues stem from the challenge of the mixed and fragmented mode of public-priv ate financing of our pluralistic health care system. We base this argument on (1) an in-depth review of Oregon's and Tennessee's five years of experience with broad coverage reform in the context of the United States health care system and on (2) a more abbreviated review of ot her state experiences in providing health care coverage. We conclude from our review that when the will exists, states can substanti ally expand coverage. However, as one moves up the income scale, political support and resources are harder to come by. Further, concerns grow about t he interface of public and private coverage, with issues of "crowd out" and other distributional questions dominating the discussion of coverage expan sion as policy makers focus less on how to cover people than on how to make sure one kind of coverage doesn't preempt another. Concern for crowd out c an then lead to policies that keep out some of the very people policy maker s may want to cover. In this context the: question whether states or the fe deral government is more likely to succeed in expanding coverage is eclipse d by the more fundamental challenges raised by pluralism. Neither federal n or state government is likely to be fully successful without first identify ing ways of better coordinating public and private activities and resources to provide continuous and affordable coverage.