Healthcare reform in the US. Momentum shifts from federal to state governments.

In the absence of federal leadership on comprehensive healthcare reform, a major restructuring of the delivery of healthcare in the US has occurred in the private sector and is well underway in many state legislatures. The influence of managed care continues to be pervasive. In 1994, 80%, or some 230 million, of the insured population in the US were included in a managed-care setting of some kind. This represents a 6-fold increase over the preceding decade. Healthcare reform has remained high on the list of legislative priorities for many states. Although initiatives vary, an increasing number of states are seeking federal waivers to broaden and restructure their Medicaid programmes so that groups of uninsured individuals can be included and all Medicaid recipients shifted into a managed-care setting. This paper provides an overview of the Medicaid waiver programme and other state initiatives. In addition, the paper reviews a decision of the US Supreme Court that recently established guidelines for states considering the imposition of surcharges or other revenue-generating mechanisms on private insurers as a means of funding uncompensated care.