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Open Access Publications from the University of California

Swimming Upstream: The Hard Politics of Health Reform in California


This report provides a comprehensive examination of political, policy, and economic factors that contributed to the failure of California's 2007 health care reform effort. Specifically, the report focuses on the intersection of four factors: 1) The impacts of long-term systemic forces or limitations — including economic forces, constitutional provisions, and federal statutes —over which state decision makers may have little control; 2) The critical policy challenges and the efforts to overcome them; 3) The perceptions, positions, and impact of major interest groups; and, 4) The role of political and legislative leadership in defining, promoting, and mobilizing support for reform goals. Relying on both extensive documentation and more than 120 interviews with reform participants and knowledgeable observers between January 2007 and July 2008, the author examines how these factors influenced and ultimately undermined an effort that had the support of both Democratic legislative leaders and a Republican governor. The report also examines the efficacy of sweeping reform efforts, highlighting the multiple challenges to comprehensive reform and the systemic rules which favor incremental over comprehensive reform. It concludes that, especially in difficult economic times, federal reform — or at least increased federal financial support — may be the key to insurance coverage expansions. Walter Zelman, PhD, was a visiting researcher at the UCLA Center for Health Policy Research and a visiting professor in the Department of Health Services at the UCLA School of Public Health during the data collection phase of this project. He is now Chair of the Department of Health Science and California State University, Los Angeles. Support for the data collection was provided by grants from The California Endowment and the University of California (UC) Office of the President, California Program on Access to Care.

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