There is broad agreement in the United States that it would be desirable to lower the cost and improve the quality of healthcare and to broaden health insurance coverage. There is much disagreement about how this trio of goals is to be accomplished. Proposals from various political perspectives have one thing in common: they assume the key to lower costs and better care is to reconfigure the insurance system.

However, health insurance reform should not be the sole fixation of reform efforts. States have (and should have) substantial control over the delivery of healthcare—and not solely or principally in the area of insurance reform. To make maximum use of state powers in improving care, it is vital to see how institutions work in other states. In the Healthcare Openness and Access Project (HOAP), Darcy N. Bryan, Jared M. Rhoads, and Robert F. Graboyes present state-by-state measures of the flexibility and discretion that patients and providers have in managing health and healthcare.

HOAP seeks to raise important questions, such as how open each state’s laws and regulations are to institutional variation in the delivery of care and how much access to varying modes of care this confers on the state’s patients and providers. The goal of HOAP is to encourage these types of questions rather than to provide definitive answers.

Background and Study Design

The years-long political struggle over the Affordable Care Act (ACA) is the most visible manifestation of the divergence of views about how to improve healthcare. The ACA represents one approach to tackling the three goals. Many on the political Left argue for more centralized public-sector control over healthcare and for a federal single-payer insurance system. Others on the political Right have offered a variety of proposals that would shift more power to private-sector entities and to states.

HOAP’s overall index averages 10 equally weighted subindexes that measure the discretion patients and providers have over broad areas of healthcare, such as public health and telemedicine. The equal weighting is an explicit recognition of the fact that no single set of weights should be considered “correct.” HOAP is constructed so that readers and researchers can alter the weights assigned to different variables to reflect their own preferences.

HOAP was originally issued in December 2016. In June 2018, the numbers were revised to reflect changes in state laws in the interim and to reflect modest changes in the HOAP methodology. Changes in state rankings reflect both of these factors, so one should be cautious about reading too much into the numeric differences between the first and second versions of HOAP.

Key Points