As the endless dispute about reforming healthcare drags on in Washington, the participants might want to note two articles that appeared in the daily AMA Morning Rounds on February 9, 2018:

The first references several state-requested innovations to Medicaid:
Quoting the Congressional Quarterly, “in addition to work requirements,… several states “want to impose time limits on how long people can stay on the program.” A couple of states “want to roll back their Medicaid expansions to cover fewer people,” and still others would like “to require drug testing or limit the list of prescription drugs they’ll pay for…”

The press already has reported on some of these proposed work requirements. As an example, The Washington Post reported on January 11 that 10 states are requesting federal permission to impose work requirements on able-bodied adults who are enrolled in Medicaid.

The second AMA article highlights the significant observation that enrollment in state-run ACA programs is up, and enrollment in programs is down:
“…A majority of the states which manage their own ACA exchanges “saw more people sign up in 2018 than last year, while 29 of the 34 states that rely on the federal government to promote enrollment saw their sign-ups fall,” according to data unveiled by the National Academy of State Health Policy. The article says 11 of the 17 state-based marketplaces had higher enrollment, while the 34 states which use had an average decline of 5.3 percent.”

Ah. Programs run by states seem to be more popular than the one run by the federal government. Interesting.

The famous U.S. Supreme Court Justice Brandeis once wrote that “the states are the laboratory of democracy.” And so it seems to be. Instead of being solely promulgated from on high, innovative experimental programs for healthcare delivery are percolating up from below. Some of these will fail. Some will succeed. And we will learn from both.

There is another relevant development. The Jan 30 New York Times reported that “Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they [will] form an independent health care company for their employees in the United States.” This is stunningly consistent with some of the proposals that we made when I was on the AMA Council of Medical Service 20 years ago. Our idea was that, in addition to employer-based healthcare, healthcare coverage could be organized by neighborhoods, churches, unions and any other combination of like-minded people. While the proposed mega-group above still would be employer-based, it would be quantitatively different from a group that is limited to employees of one machine shop.

In Germany and several other countries in Europe, healthcare plans are called krankenkassen, which might be translated roughly as healthcare ‘cash boxes.’ As it happens, these often are organized according to religious denomination, a notion better suited to European culture than ours. While we would not organize healthcare in exactly that way, the idea is one that could be adapted, as the CMS recognized.

So the ideas keep rolling out. In short, perhaps we might benefit from a little less grandstanding in Washington and a little more experience with experiments in our 50 states as we fumble our way to an improved healthcare system.

Dr. Adelman is a past president of the Wayne County Medical Society and Michigan State Medical Society as well as past member of the AMA Board of Trustees. Now retired from the practice of pediatric surgery, she is the author of The Rebel: A biography of Ram Jethmalani.