Short of the adoption of a federally run national health insurance system, the states will play an increasingly prominent role in the provision, regulation, and financing of health care in this country. Beyond the important question of whether or not the states will have the financial ability to handle this challenge there lies a more fundamental, or at least interesting, one: What is the potential consequence or significance of this increased state responsibility in health care policymaking? Are the states likely to do a good job in guaranteeing the quality of care or the equitable distribution of resources? What about the commitment of state governments to insuring access to quality health care for all who need it? Proponents of state activism argue that the states will be more responsive to local needs and are in a better position to experiment and find innovative solutions to difficult health problems. The chapters in this book would lend credence to this perspective. In states as geographically, economically, and demographically diverse as Hawaii, Massachusetts, Oregon, and Texas, policymakers have shown extraordinary inventiveness and sensitivity in dealing with some of our most intractable health-related problems.
Yet not all observers are sanguine about the prospects of an increasing reliance on state governments as the main protectors of the public's health. Frank Thompson, for example, notes that there is considerable suspicion about the "commitment, capacity, and progressivity" of the states when it comes to social programs in general and health policy in particular. He suggests that some states have been reluctant to support redistributive social programs, including health care for the needy or publicly financed insurance systems. The explanation for this lack of commitment is often traced to a variety of economic pressures, including the power exercised by both industry and statewide medical providers. "Presumably, jurisdictions must above all be concerned with protecting their fiscal base and spurring economic growth. More generous health policies, especially redistributive ones, impede this development. Such generosity may drive up state taxes, thereby discouraging firms and affluent individuals from remaining in or moving to the state." 32
Thompson also notes reservations about the fiscal and administrative capacity of the states to formulate and implement innovative health policies effectively and efficiently. Especially troubling to some