Health care reform at the subnational level: An analysis of the diffusion of health policy innovations among American states.

Abstract

This dissertation uses the framework of Walker's (1969) seminal study on the diffusion of policy reforms to identify independent variables which help explain why some states are more likely than others to be innovative in the health care arena. The quantitative analysis of state actions uses an index of eight key health reform areas as the dependent variable. The central conclusion is that health care diffusion occurs most quickly in states which have historically been innovators in other policy areas. The findings also suggest that diffusion of health care policy seems to be invigorated by the lessening of federal preemptions. The dissertation also includes case studies of Oregon, Hawaii, and Oklahoma. The findings here emphasized the importance of history, political culture and political leadership in shaping health care innovation. The research concludes with an assessment of the movement toward managed care among the states, arguing that while such an approach may bring cost savings, it will do little to improve access to health care services.

Although the federal government has so far failed to pass any significant health care reform legislation, states continue to enact such legislation at a fairly steady pace. Spiraling increases in costs, a jump in the number of Americans without health insurance and an ongoing problem with access combined to make health care reform a high priority issue in the 1992 elections. But disagreement at the federal level over policy needed to correct these inadequacies left states to seek reform solutions of their own. The states have responded with a variety of initiatives which run the gamut from simple health insurance reforms to systemic approaches. Some states have passed a series of reforms while others have done very little.