Commonwealth Fund Australian Harkness Fellow, 2019-2020; University of Sydney, Australia.
Milbank Q. 2022 Jun;100(2):525-561. doi: 10.1111/1468-0009.12559. Epub 2022 Mar 29.
Policy Points To make progress implementing payment and delivery system reforms, state governments need to make genuine stakeholder engagement routine business, develop reforms that build on past successes, and ensure health reform is a top priority for bureaucrats and political leaders. To support state-led reform initiatives, the federal government needs to provide financial support directly to state governments; build bureaucratic capability in supporting state officials with policy design and implementation; develop more flexible, outcome-focused funding programs; reform its own programs, particularly Medicare; and commit to a long-term strategy for progressing payment and delivery system reforms.
For decades, Americans have debated whether the states need federal government support to reform health care. The Affordable Care Act has allowed the federal government to trial innovative ways of accelerating state-led reform initiatives through the State Innovation Model (SIM), which was run by the Centers for Medicare and Medicaid Services Innovation Center between 2013 and 2019. This study assesses states' progress implementing health reforms under SIM and examines how well the federal government supported them.
Detailed case studies were conducted in six states: Arkansas, Connecticut, Oregon, New York, Tennessee, and Washington. Data was collected from SIM evaluation and annual reports and through semistructured interviews with 39 expert informants, mostly state or federal officials involved in SIM. Preliminary findings were tested and refined through an online forum with health policy experts, facilitated by the Milbank Memorial Fund.
States that made the most progress implementing reforms had a strong track record and managed to sustain stakeholder, bureaucratic, and political support for their reform agenda. There was a clear correlation between past reform success and success under SIM, which raises questions about the value of federal government support beyond providing funding. State officials said the federal government could better support states, particularly those with less reform experience, by providing tailored advice that helped state officials overcome problems designing and implementing reforms. State officials also said the federal government could better support them by reforming their own programs, particularly Medicare, and committing to a long-term strategy for health system reform.
States can make some progress reforming health care on their own, but real progress requires long-term cooperation between state and federal governments. Federal initiatives like SIM that foster cooperation between governments should be continued but refined so they provide better support to states.
为推动支付和交付系统改革取得进展，州政府需要将真正的利益相关者参与作为常规工作，制定基于以往成功经验的改革措施，并确保卫生改革成为官僚和政治领导人的首要任务。为支持州主导的改革举措，联邦政府需要向州政府提供直接财政支持；在政策设计和实施方面为州官员提供官僚能力支持；制定更灵活、以结果为导向的资助计划；改革自身项目，特别是医疗保险；并承诺制定长期战略推进支付和交付系统改革。
几十年来，美国人一直在争论各州是否需要联邦政府的支持来改革医疗保健。《平价医疗法案》允许联邦政府通过医疗保险和医疗补助服务中心创新中心在 2013 年至 2019 年期间运行的州创新模式（SIM），尝试创新方式来加速州主导的改革举措。本研究评估了各州在 SIM 下实施卫生改革的进展情况，并考察了联邦政府对其的支持程度。
在六个州（阿肯色州、康涅狄格州、俄勒冈州、纽约州、田纳西州和华盛顿州）进行了详细的案例研究。数据来自 SIM 评估和年度报告，并通过对 39 名专家（主要是参与 SIM 的州或联邦官员）的半结构化访谈收集。在密尔班克纪念基金会组织的在线论坛上，由卫生政策专家对初步调查结果进行了测试和完善。
在实施改革方面取得最大进展的州拥有强大的业绩记录，并设法维持了利益相关者、官僚和政治支持其改革议程的支持。过去改革的成功与 SIM 下的成功之间存在明显的相关性，这对联邦政府支持的价值提出了质疑，超出了提供资金的范围。州官员表示，联邦政府可以通过提供帮助州官员克服设计和实施改革方面问题的定制建议，更好地支持各州，特别是那些改革经验较少的州。州官员还表示，联邦政府可以通过改革自身项目，特别是医疗保险，以及承诺制定长期的卫生系统改革战略，更好地支持他们。
各州可以在没有联邦政府支持的情况下自行推进医疗保健改革，但真正的进展需要州和联邦政府之间的长期合作。联邦政府应该继续推行像 SIM 这样促进政府间合作的举措，但需要加以改进，以便为各州提供更好的支持。
