Commissions, Clubs, and Consensus: Florida Reorganizes for Health Reform

Prologue: When it comes to medical care and health insurance, Florida is a state of extremes. It has a very large population of uninsured residents; it has a very large population of elderly Americans, virtually all of whom are insured by Medicare; and its Medicare expenditures per eligible beneficiary are the highest in the nation. The magnitude of the problems Florida's health care system faces, not to mention the influence wielded there by a staggering array of private interests, suggests that the Sunshine State might lag behind other jurisidictions in pursuing reform. But as Lawrence Brown points out in our lead essay, such is not the case. Florida has taken several important reform steps over the past decade, the most recent of which Brown discusses in detail. Brown underscores the important role played by Governor Lawton Chiles in the search for policy reforms. Assuming office with big plans for improving Florida's physical infrastructure and social services, Chiles soon recognized that health care was eating up much of the money he had hoped to use for his own priorities. Chiles's determination to act gained force when he attended a meeting of the National Governors' Association and eloquently argued that states could not afford to wait to pursue health care reform. Having articulated the goal, he returned home with a new commitment to make it happen. Brown, a political scientist, received his doctorate in political science from Harvard University. He is a professor and head of the Division of Health Policy and Management at the Columbia University School of Public Health. Brown has written on a variety of subjects for Health Affairs , including the political evolution of federal health care regulation (Winter 1992) and a review of Oregon's Medicaid rationing plan (Summer 1991). Abstract: This paper explores the political dynamics by which a health reform leader state— Florida—engineered an ambitious reorganization of state health agencies as an expected prelude to bolder policy measures before the end of 1994. Demographic and fiscal pressures spurred the state to action, but its success at innovation demands a political explanation. This narrative highlights Florida's patient quest, by means of commissions and task forces, for common ground among parties of diverse dispositions; the sagacity of would-be innovators in wielding a potent policy “club”—the prospect of a single-payer system—to encourage a search for common centrist ground; and the consensus- and coalition-building skills of the state's leading executive and legislative figures. Florida's political skill has sustained impressive departures, but the hardest questions—how to finance universal coverage, how to secure universal access, and how to keep it all affordable—remain to be answered.