Chapter 1 of The Great Experiment

The case for competition, choice and a healthy federalism

Chapter 1 of The Great Experiment

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Are We All Federalists Now?

• The excessive claims and ambiguities of the Affordable Care Act have opened important opportunities to reassert state-level leadership and innovation in health policy
• Facilitating greater jurisdictional competition among states to provide and regulate health care should be designed to limit each state’s current monopoly-like political powers based on geographic factors alone.
• States can test and demonstrate new models of policy reform until their broader adoption reaches a critical tipping point for more of a national policy consensus.
• States still face longstanding institutional constraints (a fractured regulatory system, dependence on federal financial subsidy rules, their underlying resource base, and an uncertain but unfriendly federal policy climate) that limit how much health reform they can achieve on their own.
• Nevertheless, states should take a more assertive role in ensuring access to individuals with serious pre-existing health conditions, expanding choices in health insurance regulation, restructuring their Medicaid programs, and developing actionable information for better health care decisions.        
• Real health reform is needed at both the state and federal levels. It will take a few more shovels first to bury most, if not all, of the Affordable Care Act and then to dig a way out to a market-based solution that relies on state-level policy innovation in key areas.