Time for States to Retake Control of Health Care Policy

In January, a new president and Congress will have no choice other than to revisit the harsh political terrain of health care policy.

Washington today, after all, is arguing over why, not whether, the Affordable Care Act is in trouble.

One can choose to blame Democratic overreach or Republican intransigence, but the facts are clear: Premiums are soaring, patient choices are narrowing, exchanges are hollowing out, co-ops are failing and funds to bail out insurers are growing scarce.

In this environment, the states - red and blue alike - have an opportunity to reassert their primacy in health care policy. The ACA battle and other debates that preceded it have left the impression that health care policy occurs only in Washington and revolves solely around health insurance.

But the real soul of health care lies in the hands of the states.

Governors, legislatures and state agencies have enormous power over the care their residents receive. States largely control the licensing and oversight of health care professionals, the capacity of hospitals to grow and innovate, the structure and taxation of medical businesses, and the letter and enforcement of tort and contract laws.

With the advent of digital medicine, states can either enable or obstruct new technologies, such as telemedicine. For all of Washington's influence over health insurance, state insurance commissioners also play a pivotal role in how and whether their residents obtain coverage and what that coverage looks like.

For these reasons, the Mercatus Center at George Mason University is releasing its Healthcare Openness and Access Project. It's a toolbox of state-by-state measures of the flexibility and discretion that patients and providers have in managing health and health care.

The market-oriented research center's project combines raw data series into nearly 40 indicators of openness and access. The indicators are then combined to produce 10 subindexes with which to rank broad areas of state health care policy. The subindexes, in turn, are averaged to produce the HOAP index, which yields an overall ranking of the 50 states and the District of Columbia.

Judging by the HOAP index, the top five states in terms of openness and access are (in descending order): Idaho, Montana, Missouri, Mississippi and Utah. By this index, the five least open and accessible states (again in descending order) are: Rhode Island, Connecticut, New York, New Jersey and Georgia.

As authors of the HOAP, we consider these rankings to be meaningful and useful, but we stress in the strongest of terms that they are not definitive and final. These rankings should begin conversations, not end them.

The HOAP rankings do not imply, for example, that Georgia is bad and therefore should adopt Idaho's laws. Rather, policymakers in Georgia might use the HOAP data to spark discussion over whether some of what Idaho does might work well in Georgia. At the same time, policymakers in Idaho might look at New York's higher score on the public health subindex and ask whether New York can teach Idaho a thing or two.

We designed the HOAP so any user can challenge the basic premises of the index, the 10 subindexes, the rankings, and the dozens of indicators and other data series. A user who wishes to place more significance on medical liability laws and less on telemedicine can apply his or her own weights to the data and create customized indexes and rankings.

The last thing we the authors wish to do is replicate the experience of the World Health Organization and its rankings of national health care systems. Last produced in 2000, the WHO's project began with a valuable database of information that quickly degenerated into an ideological bludgeon to shut down conversation worldwide. In contrast, we intend for the HOAP data to be poked, prodded, tweaked, discussed and challenged.

Health, after all, is a journey, not a destination.