u.s. intergovernmental system - 'federalism' - and u.s. lobbying 'system' combine (there are about 750 health care trade associations in d.c.) to work against comprehensive legislation...
re. latter, health care is issue in which *iron triangles* - cozy relationship between federal dept/interest groups/members of congress - have been replaced by *issue networks*, networks flourished with growth in number of small, narrowly focused, highly specialized interest groups, while lobby arena is more 'contested' than iron triangle arrangement, environment comprised of coalitions of temporary allies that last only as long as given issue is 'hot' by no means produces 'good' legislation (or any at all, for that matter)...
moreover, 'contested' networks are far from 'equal opportunity' arenas, in case of health care: some powerful interests - american hospital assn, american medical assn, tobacco companies, drug makers, business (national association of manufacturers, chamber of commerce) align against 'reform'...
powerful insurance industry, specific health care provider assn's (i.e., podiatrists, dentists, chiropractors, nurses, optometrists, etc.) and medical school assn want specific kinds of 'reform' (they agree on certain things, not on others)...
pro-'reform' groups, including consumer groups, child welfare orgs, american academy of family physicians, physicians for national health program, some private companies, organized labor lack comparable resources of their opponents *and* they disagree both generally & specifically re. policy proposals (organized labor has, itself, been split, whatever became of group that a number of union presidents put together called labor committee for national health insurance)...
long and short of situation is that high levels of frustration with u.s. health care for many years have made for little progress towards establishing any national system of health care insurance (btw: existing system for most who have health insurance is corporate/for-profit 'socialized' system of group insurance), failure of federal government to act has pushed states to address extending health coverge to more people (as well as to deal with escalating costs)...
massachusetts was first to adopt so-called 'play or pay' plan requiring employers of more than 5 workers to make health insurance available and to pay portion of premium, to help small-business owners with costs of negotiating with insurance companies, they could deposit money into state trust fund that would purchase coverage from private carriers, if memory serves, early '90s downturn in massachusetts economy left state without revenues to implement the plan, then, after republican william weld was elected governor, he vetoed implementation legislation, and proposed a diluted version of 'play or pay', any listers with more updated info about/experience with massachusetts program...
minnesota attempted similar plan, it too required employers to provide health insurance, it also attempted eased cost 'burden' to small business owners by creating state-run health insurance pool financed by minimal tax on all medical services provided in the state, uninsured persons could buy into plan for a premium adjusted to income level, again, any info about how this has worked...
any other examples out there (extent to which florida has acted is limited to program called 'kidcare' in which low-income parents/guardians can purchase insurance for their children)... mh