States and health care reform: the importance of program implementation

The recent debate on national health care reform marked another case of policy being considered without reference to how--or even if--it could be implemented. The debate revolved around broad issues, such as universal versus partial coverage, mandatory versus voluntary alliances, and the respective roles of government and the market in health care. The ease or even the possibility of successful implementation was not an ingredient in evaluating proposals. The burden of making health care reform work falls to the states. Whether in response to national reform or in implementing their own programs, they must move from a general reform blueprint to an actual program that delivers services. The hands-on role of the states in designing and operating programs makes their implementation duties both unavoidable and critical. This chapter explores implementation issues that should be considered an integral part of planning for health care reform, at both the federal and the state level. The chapter has two goals. First, it makes a case for altering the usual approach to designing reform and recommends paying attention to implementation early in the policy process, rather than treating it as an afterthough. Second, it is intended to help policymakers design implementable programs and anticipate pitfalls. To achieve these goals, it examines the state role in health care reform; state capacity to carry out this role; examples of state health care reform initiatives and lessons for implementation drawn from these efforts; and barriers to successful implementation. The chapter concludes with recommendations for policymakers.