United States puzzle Thelegalization of gay marriage began in a few states and quicklybecame national policy. Could reforming health care follow the sametrajectory? (Photo: Shutterstock)

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Last week, California's new governor, Gavin Newsom, promised to pursuea smörgåsbord of changes to his state's health care system:state negotiation of drug prices, a requirement thatevery Californian have health insurance, more assistance to helpmiddle-class Californians afford it and health care forundocumented immigrants up to age 26.

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The proposals fell short of the sweeping government-run single-payer plan Newsom hadsupported during his campaign — a system in which the stategovernment would pay all the bills and effectively control therates paid for services. (Many California politicians before himhad flirted with such an idea, before backing off when it wasestimated that it could cost $400 billion a year.) But in firing off this openingsalvo, Newsom has challenged the notion that states can'tmeaningfully tackle health care on their own. And he's notalone.

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A day later, Gov. Jay Inslee of Washington proposed that hisstate offer a public plan, with rates tied to those of Medicare, tocompete with private offerings.

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Related: Forget Medicare for All; more states eye Medicaidbuy-in

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New Mexico is considering a plan that would allow any resident to buy in tothe state's Medicaid program. And this month, Mayor Bill de Blasioof New York announced a plan to expand health care access touninsured, low-income residents of the city, including undocumentedimmigrants.

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For over a decade, we've been waiting for Washington to solveour health care woes, with endless political wrangling and mixedresults. Around 70 percent of Americans have said that health care is “in astate of crisis” or has “major problems.” Now, with Washington intotal dysfunction, state and local politicians are taking up thebaton.

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The legalization of gay marriage began in a few states andquickly became national policy. Marijuana legalization seems to beheaded in the same direction. Could reforming health care followthe same trajectory?

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States have always cared about health care costs, but mostlyinsofar as they related to Medicaid, since that comes from statebudgets. “The interesting new frontier is how states can use statepower to change the health care system,” said Joshua Sharfstein, avice dean at Johns Hopkins Bloomberg School of Public Health and aformer secretary of the Maryland Department of Health and MentalHygiene. He added that the new proposals “open the conversationabout using the power of the state to leverage lower prices inhealth care generally.”

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Already states have proved to be a good crucible forexperimentation. Massachusetts introduced “Romneycare,” a systemcredited as the model for the Affordable Care Act, in 2006. It nowhas the lowest uninsured rate in the nation, under 4 percent. Maryland has successfully regulated hospitalprices based on an “all payer” system.

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It remains to be seen how far the West Coast governors can taketheir proposals. Businesses — pharmaceutical companies, hospitals,doctors' groups — are likely to fight every step of the way toprotect their financial interests. These are powerful constituents,with lobbyists and cash to throw around.

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The California Hospital Association came out in full support of Newsom's proposals to expandinsurance (after all, this would be good for hospitals' bottomlines). It offered a slightly less enthusiastic endorsement for thedrug negotiation program (which is less certain to help theirbudgets), calling it a “welcome” development. It's notable that hisproposals didn't directly take on hospital pricing, even thoughmany of the state's medical centers are notoriously expensive.

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Giving the state power to negotiate drug prices for the morethan 13 million patients either covered by Medicaid or employed bythe state is likely to yield better prices for some. But pharma isan agile adversary and may well respond by charging those withprivate insurance more. The governor's plan will eventually allowsome employers to join in the negotiating bloc. But how that mighthappen remains unclear.

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The proposal by Washington Gov. Inslee to tie payment under thepublic option plans to Medicare's rates drew “deepconcern” from the Washington State Medical Association, whichcalled those rates “artificially low, arbitrary and subject to thepolitical whims of Washington, D.C.”

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On the bright side, if Newsom or Inslee succeeds in makinghealth care more affordable and accessible for all with a newmodel, it will probably be replicated one by one in other states.That's why I'm hopeful.

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In 2004, the Canadian Broadcasting Corp. conducted an exhaustive nationwide poll to select the greatest Canadian ofall time. The top-10 list included Wayne Gretzky, Alexander GrahamBell and Pierre Trudeau. No. 1 is someone most Americans have neverheard of: Tommy Douglas.

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Douglas, a Baptist minister and left-wing politician, waspremier of Saskatchewan from 1944 to 1961. Considered the father ofCanada's health system, he arduously built up the components ofuniversal health care in that province, even in the face of aninfamous 23-daydoctors' strike.

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In 1962, the province implemented a single-payer program ofuniversal, publicly funded health insurance. Within a decade,all of Canada had adopted it.

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The United States will presumably, sooner or later, find a modelfor health care that suits its values and its needs. But 2019 maybe a time to look to the states for ideas rather than to thenation's capital. Whichever state official pioneers such a systemwill certainly be regarded as a great American.

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Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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