Barrilleaux Charles, Brace Paul
Florida State University, USA.
J Health Polit Policy Law. 2007 Aug;32(4):655-83. doi: 10.1215/03616878-2007-021.
We identify two policy strategies that state governments pursue to reduce uninsurance, and we classify policies as being either state based or market based. The two policy strategies are distinguished by whether states rely on the institutional capabilities of the state or market processes to provide insurance. We develop and test models to explain states' adoptions of each type of policy. Using Poisson regression, we evaluate hypotheses suggested by the two strategies with data from U.S. states in the 1990s. The results indicate that institutionally more-capable state governments with strong liberal-party presence in the legislature adopt more state-based policies and fewer market-based policies. By contrast, the model of market-based, business-targeted reforms reveals that government capability plays a smaller role. Instead, these policies are driven by economic affluence, political competition, higher incomes, greater uninsurance, and more previous attempts to address the uninsurance problem. These findings reveal distinct institutional, partisan, electoral and demographic influences that shape state-based and market-based strategies. First, policy choices can be driven by the presence or absence of state capability. The domain of feasible policy choices open to states with institutional capability may be decidedly different than that available to states with fewer institutional resources. Second, while market-based policy approaches may be the most feasible politically, they may be the least successful in remedying practical uninsurance issues. These results thus reveal that institutional characteristics of states create an important foundation for policy choice and policy success or failure. These results would suggest that the national government's strategy of pursuing market-based solutions to the problem will not result in its being solved.
我们确定了州政府为减少未参保情况而采取的两种政策策略，并将这些政策归类为基于州的政策或基于市场的政策。这两种政策策略的区别在于，各州是依靠州的机构能力还是市场机制来提供保险。我们开发并测试了模型，以解释各州对每种政策类型的采用情况。使用泊松回归，我们利用20世纪90年代美国各州的数据评估了这两种策略所提出的假设。结果表明，在立法机构中有强大自由党存在、机构能力更强的州政府会采取更多基于州的政策，而采取基于市场的政策较少。相比之下，以市场为基础、以企业为目标的改革模式表明，政府能力所起的作用较小。相反，这些政策是由经济富裕程度、政治竞争、更高的收入、更大的未参保率以及之前更多解决未参保问题的尝试所驱动的。这些发现揭示了影响基于州的策略和基于市场的策略的不同的制度、党派、选举和人口因素。首先，政策选择可能受州能力的有无所驱动。有机构能力的州可选择的可行政策领域可能与机构资源较少的州有很大不同。其次，虽然基于市场的政策方法在政治上可能是最可行的，但它们在解决实际的未参保问题上可能最不成功。因此，这些结果表明，各州的制度特征为政策选择以及政策的成败奠定了重要基础。这些结果表明，联邦政府采取基于市场的解决方案来解决该问题的策略不会带来问题的解决。
