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single-payer plan. But the long-term trends augur well for the more activist, progressive branch
of the labor movement. The trend of union alignment with the public sector, rather as acting as a
broker between the public and private spheres, is likely to accelerate. Although 55 percent of
union membership is now in the private sector, in the next decade unions will have majority
public sector membership. “The center of gravity in the union movement,” one economist notes,
“will shift from private to public.”
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As that shift accelerates the pressure on state Democrats
will likely mount to shift farther to the left on health reform.
Conclusion
States face various unpleasant tradeoffs in crafting and enacting health care reform.
Larger political and economic changes in the past two decades have made these choices
particularly unpalatable and difficult. The economic downturn, combined with the drying up of
funds from the tobacco settlement,
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makes the growth of public programs harder to finance and
private sector regulations harder to justify. This paper has shown the ways in which the
coexistence of public and private health insurance both contributes to and reflects differences in
ideas about the proper role of government and differences in institutional and interest group
orientations. Larger political developments in the last twenty years have reduced the ability of
state parties and labor to address this fragmentation through acting as links between public and
private health insurance.
It is important to note that in the long term the effects of decline of old labor and the rise
of issue-driven, polarized parties are not unambiguously negative or positive. Many state voters
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Worsham, 16.
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Martha A. Derthick, Up In Smoke: From Legislation to Litigation in Tobacco Politics (Washington, D.C.
:Congressional Quarterly Press, 2002).
Convention