Some of the liveliest discussions at this year’s AcademyHealth Meeting were on state reform. The Massachusetts legislation and now implementation has served as an engine for discussion for many previously jaded health systems scholars, reformers, and activists. With California now following Massachusetts’ lead in proposing universal coverage, many scholars are wondering how this scenario will play out to 2009 and a new administration.

Health policy researchers are counting how many states it would take to create a tipping point to induce federal legislation creating universal access. Besides Massachusetts and smaller programs in Vermont and Maine, California has legislation on the table, and other generally large and Democratic-leaning states, such as Illinois, Pennsylvania, and New York, are discussing programs that either start with universal coverage or start with universal coverage for kids. This discussion, however, is not limited to “Blue” states, as states such as Colorado and Kansas engage in discussion for reforms in finance and coverage of their residents. Even Texas has passed expansions to its SCHIP coverage.

SCHIP reauthorization was another topic of interest at AcademyHealth. For virtually all health services researchers and state policymakers, SCHIP has been a notable success. First and foremost, it has actually worked. It has significantly decreased uninsurance among low-income children, and children are the only group not to have suffered declines in coverage during the 1997-2005 period. SCHIP has also generated a great deal of data and research on program design, enrollment outreach, and retention, keeping researchers employed but more significantly having important spillover effects on Medicaid and getting more Medicaid-eligible beneficiaries enrolled and retained.

There have been some bumps on the road, and the Deficit Reduction Act (DRA) eligibility requirements are a big bump, but most researchers and certainly state SCHIP directors hope that in the current reauthorization process, SCHIP programs will be allowed to expand income eligibility requirements to something substantially higher than 200% FPL and have more flexibility to offer premium assistance or subsidies to families. SCHIP directors hope to retain the flexibility they have had on easing enrollment, using techniques like passive enrollment and express-lane eligibility, but many SCHIP advocates are open to ceding back to the federal government authority to standardize quality measures across the states.

The SCHIP reauthorization discussion also has important ramifications for the state initiatives. Many of the state initiatives depend on SCHIP eligibility expansion and the availability of federal dollars to provide universal coverage for kids. What happens if in the SCHIP authorization debate, efforts to find funding offsets to expand income eligibility to 300% or 350% FPL fail, and states are mandated to limit SCHIP eligibility to 200% FPL? Will states such as Pennsylvania and New York continue their initiatives without SCHIP expansions?

Prior to the passage of SCHIP in 1997, several states such as New York and Florida had already established expanded coverage for kids, and these programs were then grandfathered in under the SCHIP legislation. This example of states taking initiative to then prod the federal government to take action and make federal dollars available has not been lost on the states, or on advocates for children. Some of the states considering providing universal access to insurance to their citizens or at least to all their kids are hoping that their example will prod the federal government to act after 2009 and perhaps even grandfather in their particular programs with the requisite flexibility and funding required to sustain them.

This push-pull relationship, sometimes known as federalism, is somewhat curiously missing from the presidential campaign. It is fascinating to watch the dynamism and creativity of the states float under the radar of the presidential campaign. The leading Democrats have had little to say about states’ respective reform efforts. Both Senator Clinton and Senator Obama represent states in the forefront of the reform efforts. Senator Obama also played a key role in the Illinois legislature in promoting a study of health system reform. It would be interesting to know how their experiences with their home states have informed the programs they propose and what role they see for the states in a federal reform program. Equally invisible has been any discussion of the potential success, viability, or generalizability of state reforms on the part of Republican candidates. Governor Romney and Governor Huckabee have both had extensive and illuminating experience in promoting legislation for significant health care reform. Romney led the Massachusetts reforms, and Huckabee has been a leader in public health legislation on obesity and education.

Perhaps we have to thank the current administration for making state creativity in health care reform both necessary and ongoing. Let’s hope that as the presidential campaign soldiers on, the creativity of the states informs the debate and engages the federal government to act in both a responsible and creative fashion.