Can states pick up the health reform torch?

10.1056/nejmp1001439 nejm.org e29(1) ton is still taking the full measure of Senator Scott Brown’s victory in Massachusetts, but among seasoned observers, the election’s potential fallout for health reform was evident even before the first votes were cast.1 The political narrative of the Brown victory is the stuff of legend: the loss of a Senate seat held by an iconic figure who devoted his half-century political career to the very issue now at the center of events. The policy narrative is just as astounding, since Massachusetts’ health care reform plan (for which Brown voted) provided the basic template for federal reform. Even as the White House and Congress struggle to move forward, some observers have once again focused on the states. To be sure, the Senate bill, unlike its House counterpart, uses a state-based approach to the operation of health insurance exchanges, the purchasing marts through which eligible individuals and small businesses would gain access to affordable coverage. But unlike independent state reforms, the House and Senate bills offer a national solution for the residents of all states, not just those who live in jurisdictions with the political and financial means to pursue change. Why Congress has reached a moment of national action is not hard to grasp. The insurance crisis has been with us a long time: only its magnitude has changed, with health care costs now exceeding 17% of the gross domestic product and with 17 states in which 15% or more of the nonelderly population is uninsured.2 States have had decades to enact broad reforms, yet the record has been one of futility despite enormous effort. Massachusetts, the one standout in this regard, found itself in 2006 remarkably positioned to move. The state’s social culture favored government involvement; its Republican governor and Democratic legislature aligned on a coverage mandate, greater insurance regulation, and strong Medicaid restructuring. A relatively low proportion of the population was uninsured, and the state enjoyed a seemingly healthy economy and the financial wherewithal to act (chiefly as a result of the Medicaid restructuring that was the basis of reform). As its financial Can States Pick Up the Health Reform Torch?