Implementation, System Redesign, and Other State Strengths

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In recent years, a lack of national consensus about how to address the growing number of uninsured people has prompted work at the state level to enact incremental, substantial, and comprehensive coverage reforms as well as other initiatives that address cost and quality. These states could not wait; due to the immediacy of constituent concerns—of individuals, employers, and other stakeholders in the health care system—state governors and legislatures felt compelled to act.  Results were mixed.  States have experienced both important successes and enlightening failures that can help inform a national plan and help frame the best structure for any new federal-state partnership.

States play a critical role in advancing coverage expansions and other health reforms by testing new ideas, both politically and practically.  Because health care delivery is largely local, states are closer to the action when it comes to implementing some of the delivery and payment systems changes that are needed to truly transform the health care system. This proximity and flexibility in system redesign is a key strength for states.  In addition, states have first-hand knowledge of their local landscape and relationships with the stakeholders that will be necessary to change the system. Much of the work related to implementing insurance reforms, delivery system redesign, and public health strategies traditionally have been led by states.
On the other hand, there are numerous limitations for states in these areas as well, including some structural and financial constraints that keep certain potential levers out of their reach. In these areas, the federal government offers key advantages.