Part of last week I was with many of my fellow health and consumer advocates in Washington, DC. I learned about all the good and promising efforts they were embarking on in states like Minnesota, Oregon, Ohio, Colorado, Illinois, Maryland, Pennsylvania, Washington, Maine, Vermont, and yes, my previous home states in New York and New Jersey.
They were using the progress that we made in California in their own efforts. In one blue state, advocates are pushing the most progressive legislator in their StateHouse to improve his nascent proposal on the employer contribution, to be more like what was agreed to by Assembly Speaker Nunez and Governor Schwarzenegger.
Our efforts, in short, have already been helpful to my colleagues in other states. I know other states are already borrowing some of the policy elements that were developed in this exhaustive process.
But it’s cold comfort for Californians, now that the bill has stalled. What is the implication for my colleagues in other states?
With apologies to my New York background, if we could have made it here, we could made it anywhere. It would have been a boon to efforts around the country and in DC.
But there’s reasons why the opposite is not true.
California has all the obstacles that seem to frustrate federal reform, but without the flexibility or financing ability.
* National health reform is hard because health care has an enormous number of stakeholders that are impacted by any change, and it’s hard to get a consensus, especially in a country so large and diverse, both in terms of the on-the-ground infrastructure, and in terms of ideology. On health care, Washington, DC has been polarized on any solution (see the SCHIP debate), which has resulted in either neglect or gridlock.
* It is because of this gridlock that the states have taken the lead with their own efforts. And while states have clear jurisdiction and responsibilities in many health areas, state health reform is hard because there’s contraints in policy and process: Medicaid rules, ERISA, and the biggest of all, the ability to finance the system overall. States have balanced budget requirements and it’s harder to raise revenues. (Among other things, we don’t have a Bush tax cut to repeal, as is the suggestion of many Democratic presidential candidates.)
A nation-sized state, California has the size and diversity that makes consensus hard (think Berkeley and Bakersfield, Orange County and Oakland), and has one of the worst problems, with Californians more likely to be uninsured than in all but five states. As we have said before, Massachusetts, with 10% uninsured, had to close a gap; California, with nearly 20% uninsured, has to jump a chasm.
So California has all the obstacles at the federal level, with all the obstacles at the state level, plus some of California’s very own–in particular the 2/3 vote rule to pass any revenues in a legislators (a threshold only Arkansas and Rhode Island share) that empowers a solid Republican blockade against taxes; and the ballot-box culture of initiatives and referendum.
Yet in spite of all this–look how far we have come.
In the past five years, the legislature has passed four measures to dramatically expand health coverage–SB2; AB772; SB840; AB8. Until recently, it was the Governor that was the obstacle. The Assembly and the Governor agreed on a fifth proposal, AB x1 1, and now it’s the Senate.
Despite all the obstacles, it’s clear that political will can make it happen, from Senate President John Burton in 2003 to Assembly Speaker Fabian Nunez and Governor Arnold Schwarzenegger in this special session.
We just don’t yet have the needed political will. But that is something we can build, and change, and make happen.
I cringed when some Democratic Senators in committee made comments about the Legislature–talking about themselves!–being unable to functionally monitor and make adjustments to a health reform if they are needed. There are clearly constraints with health reform, but that sounded like abdicating leadership. Finding an excuse, rather than solving a problem.
If I learned anything in the past five years, it is that reform in California is possible, but that it takes political will and leadership from multiple sources, a major effort to engage and mobilize Californians to demand and expect results, and that it also takes multiple efforts and time to make it happen.
This wasn’t the first year of health reform, and it won’t be the last. We’ll see to it.