“All politics is local” is a maxim coined by Thomas “Tip” O’Neill, former Speaker of the US House of Representatives, and most people probably think that’s a good thing and a key feature of our democracy. And, of course, most people know that “all health care is local.” So even though the fate of the Patient Protection and Affordable Care Act (ACA) is being debated on a national stage today, the future of health reform is likely to take on a local flavor, no matter who prevails on November 6.
Indeed, what states do or do not do—and how well they do it—will largely determine how well the ACA achieves its goals. In the case of health care, whether this reliance on state variation promotes or retards the rapid reformation of our health care system is an open question.
The local variations in care unrelated to patient status reported by the Dartmouth Atlas of Health Care have long demonstrated the inconsistencies and frustrating discrepancies in care in America. On a more positive note, states have long been laboratories for innovations in health care delivery and financing. Think about Oregon’s process for prioritizing services covered by its Medicaid program, Tennessee’s TennCare Medicaid approach, and Massachusetts’ universal health insurance. Perhaps surprisingly, the last several months have seen an uptick in “federalism” in health care, despite the passage of the ACA.
The Obama administration set the tone for this state-by-state approach when it sent back to the states a number of significant decisions which a plain-English reading of the ACA suggests that Congress and the President had agreed were in the federal domain. Most striking was the announcement that it would be up to the states to decide for themselves what an “essential benefits” package should contain. Then the Supreme Court weighed in, ruling that the decision to expand Medicaid could be made on a state-by-state basis and that rejecting new Medicaid dollars would not imperil the amount of a state’s current Medicaid check from the US Treasury. And Mitt Romney, in seeking to distance himself from his own Massachusetts health care plan, has said that the plan was applicable only to the Bay State and shouldn’t be replicated nationally. So no matter how next Tuesday’s vote turns out, health reform is certainly going to be a patchwork.
In several important respects, however, leaving such matters in local hands is an obstacle to the rapid acceleration towards a more efficient and rational system. There are obviously the confusion, cost, and irrationality of having different benefits and eligibility standards apply state by state, adding to the burdens of multistate employers, state governments, the federal exchange, and the public. But a less obvious area of variation that is not much discussed, the key question of who gets to do what in our emerging health care environment, can promote or hobble the rational and efficient implementation of the ACA.
A legislator in California once told me that the most vicious fights she ever encountered in the capitol were around this “scope of practice” issue, when ophthalmologists, optometrists, and opticians came to Sacramento with knives out to protect their own turf. This same battle is repeated specialty by specialty and also between different groups of doctors and technicians. Moreover, the question of who gets to dispense medication or give vaccines becomes not only a political fight within the health professions, but it is also tied up in turf battles between different boards for different specialties (such as the Board of Medicine, the Board of Nursing, the Board of Pharmacy, and so on), which in many states oversee the regulation of medical practice.
So we face the situation in which, as a Slate article recently pointed out, you can get a flu shot in a pharmacy in any state, but if you want the pertussis vaccine at the same location to protect yourself from a recent increase in cases of whooping cough, you can get it in Tennessee and Massachusetts but not in New Hampshire or New York.
Similarly, the tasks approved for a nurse practitioner to perform instead of a physician vary dramatically from one state to another, which has implications for the spread of innovative and generally cheaper retail medical clinics across the country. If nurse practitioners could diagnose and prescribe at the same level in every state, then it would be easier to take retail clinics to scale by counting on nurse practitioners to fill a standardized role in all states.
When asked why this patchwork of state-based regulation exists, the answer is usually “because that’s the way it has always been done.” But the more troubling reality is that this system helps each profession maintain its income by holding off competitors, typically in the name of quality, safety, or some other such noble goal.
One area in which we obviously need national standards is the provision of specialty consultation and other medical care across state lines by telehealth and other nontraditional means. Barriers even exist when health professionals want to give away their services. The Remote Area Medical group, which provides free medical and dental care for thousands of poor Americans each year, can’t use its Tennessee volunteers in Texas, Arizona, Florida, and many other states because these states won’t recognize the volunteers’ home-state credentials, even when they charge nothing for their expertise. Some states recognize the foolishness of that approach and have no restrictions, but barriers remain widespread.
State politicians are unlikely to remove these barriers. Because these decisions are largely in the hands of state legislatures and politically appointed boards rather than, for instance, a national scientifically based commission, each specialty and professional group lobbies (and provides campaign funds for) politically influential legislative leaders and members of key committees.
Health care delivery may have been mainly local in the past, but that’s changing. Academic medical centers have long tried to attract patients from around the country (and the world). Now big employers are providing significant incentives to employees to travel to contracted centers of excellence.
More importantly, science is not local. The efficacy of using lower-cost professionals to do what physicians have traditionally done must be tested and confirmed, but we prove safety and efficacy for drugs, devices, and procedures for the entire country and don’t require them to be proven over and over again in every state. It’s only in this area, where people’s professional identities, historical practices, and incomes are involved, that we let state boards, committees, and politics make what should be science-based decisions.
How might we remedy this system? National licensing standards? Federal authority to launch pilot programs? Perhaps readers have some other ideas. But retention of mid–20th century licensing and regulatory authority in the hands of states as we approach the middle of the 21st century must be urgently reconsidered.
About the author: Mark D. Smith, MD, MBA, has been president and chief executive officer of the California HealthCare Foundation since its formation in 1996. CHCF is an independent philanthropy with assets of more than $700 million, headquartered in Oakland, California, and dedicated to improving the health of the people of California.
About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.