Incrementing toward nowhere: Universal health care coverage in the states

Despite successful adoption of other health care reforms, the states collectively have been no more successful than the federal government in achieving universal coverage. Do the same forces stopping reform at the national level also restrict states? Are the incremental steps that states have taken toward coverage likely to lead to real reform? Analysis of state activity from 1988 to 2002 shows that where Democrats are in charge and where their allied interests predominate, state legislative activity on universal care is more likely. Diffusion results indicate that what was at first a policy bandwagon effect turned into a negative diffusion effect or brake on efforts to expand coverage. We are pessimistic about the long-term success of incremental efforts and instead outline the requirements for a punctuated approach.