Determinants of state-level health care reform policies, 1988--1994

Date of Completion

January 2001


Political Science, General|Sociology, Public and Social Welfare




During the late 1980s, fiscal pressures and lack of federal leadership prompted many states to undertake health care reform initiatives. As purchasers, regulators, and providers of health care services, the states are well positioned to experiment with health care system change. Within constraints set by federal law, state health care reform policies vary considerably in their approaches to containing health care costs, expanding access, reorganizing and rationalizing the health care system. This research seeks to identify determinants of cross-state variations in eleven state-level health care reform policies. ^ Three state theory variants frame the analysis. Overall, state theory is concerned with the role of government in allocating resources among competing social groups. Structural state theory emphasizes the impact of the economic dominance of particular business sectors and the presence of fiscal crisis on policy. Class dominance state theory suggests the importance of the relative unity of organized interests and the mobilization strategies they use to influence policy outcomes. State-centered state theory acknowledges the effect of government organizational capacity and policy history Donna Clarice Bird—University of Connecticut, 2001 on policy formation. Explanations from three other perspectives related to state-centered state theory—political party dominance, state political culture, and innovation diffusion—are also included. Determinants derived from all of these perspectives may affect state health care reform policies, although their degree of influence is contingent on historical and local circumstances, as well as the particular policy. ^ The analytic approach is quantitative, using data for all 50 states and relying on ordinary least squares and ordered logistic regression build models. The independent variables measure economic dominance, state fiscal crisis, interest group unity and mobilization, government organizational capacity, health policy history, political party dominance, state political culture and innovation diffusion. The dependent variables are indices based on the ultimate status of health care reform policies proposed, adopted or implemented by individual states during the period 1988-1994. Policies included in this analysis are: physician fee regulation, Medicaid managed care, health insurance premium caps, community rating, government subsidized insurance, employer and individual mandates, antitrust immunity, limits on physician self-referrals, standardized electronic claims processing and comprehensive health care data collection and analysis. ^