Notes from the laboratories of democracy: State government enactments of market- and state-based health insurance reforms in the 1990s

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.