Health Care: Looking to the States?

The new Massachusetts health care bill, which has generated very little discussion here at Daily Kos, represents a unique effort along all parts of the political spectrum to bring health coverage to 95% of the state's residents.  The particulars of the plan merit more analysis by progressives nationally, but it also, I believe, forces us to confront the question of whether it will be more productive to pursue the goal of universal coverage through the states, or at the Federal level.

The Massachusetts plan looks to me a little like a more conservative version of the Gephardt plan: a multi-pronged approach requiring businesses to provide coverage and seeking to make it less expensive for other individuals to purchase their own, while providing subsidies and expanding access to Medicaid for low-income people.  

One of the more controversial-sounding aspects is that otherwise uninsured individuals are actually required to purchase insurance, sort of like car owners are required to insure their vehicles.  As with mandatory auto insurance, this can be justified from a public-good standpoint - because it reduces costs to the taxpayers of emergency room visits, and because, when it comes to things like communicable diseases, I am healthier when my neighbor is healthier.  At the same time, making it mandatory to buy health insurance puts a responsibility on the state to find ways to lower the cost of insurance.

I don't claim to know whether this represents a rational or effective approach to providing health care.  I do know that no health care initiative is rational or effective if it cannot be made politically viable - in other words, an imperfect plan with broad bipartisan support seems preferable to an ideal-sounding plan that has no chance of passage.

And this political viability issue extends to the question of whether it is a better use of our resources to continue pushing for a Federal health care solution, or to focus on efforts at the state level.  Not all states have the resources and political will of Massachusetts, yet it's clear that state-based efforts to broaden health coverage have been gaining momentum.  As progressives, we have traditionally sought to maintain a balance between pragmatic and local steps on the one hand, and the importance of universal equality on the other.  Is a state-by-state effort on health care the way forward, or does it condemn us to a patchwork nation of separate-but-unequal health plans?