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magpul_stateline_final-2It has been said that the states are laboratories of democracy. OK, it is a little more complicated than that. Turns out Justice Brandeis in “New State Ice vs Leibmann” ACTUALLY said: “a state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.” It seems we are embarking on such an experiment, this time with health care.

The Affordable Care Act was passed with the intent to provide health care for almost all US citizens. It was to do this with minimum disruption to existing mechanisms of payment. SOOOO, people over 65 got to keep their Medicare. People who were really poor got to keep their Medicaid. People whose boss was nice enough to pay for health care got to keep getting it through their work. People who were in the military got to keep their Tricare insurance. Veterans got to keep their VA benefits. In fact, the only real changes were as follows:

  • Health “insurance”  was defined at the federal level, because it turned out a lot of people were paying for crap, especially for individual policies, and state regulators were not, well, regulating.
  • Children got to stay on their parents’ policies until they were 26, mostly because it was cheap and easy to do.
  • Preventive services were mandated because it was the right thing to do.
  • People were given subsidized access, either on the exchanges or (if they were really poor) through Medicaid, because we have a really expensive health system that rations inappropriately through cost and forces people to make irrational decisions on access.
  • Everybody was forced to pay into the system, because everyone eventually uses the system and no one wants higher taxes. In a nod to the market boosters, the money follows the people but no one gets a free ride.

Then the fighting started. After 40 votes to “repeal” (and return to the best imaginary health system in the world) and a weird Supreme Court ruling, D-day is here.

The upshot is that 24 states are doing all they can to uphold a vision of access for all of their citizens. 26 states (representing a disproportionate number of poor) are upholding a different vision. Massachusetts, now 6 years into the prototype (Romneycare) is one that is moving beyond access to better health. Don Berwick, a candidate for Governor and a physician, is selling Massachusettians (well, what do they call themselves?) on the slogan “Better Health, better care, lower cost” since 98% of the citizens are now covered.

Here in Alabama, Governor Bentley (also a physician) is proud of his record on health care as well. From the Montgomery Advertiser:

A Kaiser Family Foundation study released earlier this month found that 191,000 people will be left in a coverage gap without the Medicaid expansion, but Bentley indicated Monday he was satisfied with his decision.

“I can’t think of anything worse right now than to have expanded Medicaid and have all these people on an entitlement program right now and for this entire thing to go under, which I think is going to happen,” Bentley said. “So I think my decision is right. But I’ve always thought it’s right.”

And, when it was pointed out to him that without the additional Medicaid dollars many rural hospitals will close:

“There are some rural hospitals that may have to be redesignated as something other than a hospital,” he said. “They may have to work with the state health planning board and the (Certificate of Need) planning board as we work through these issues.”

So, as we move forward on our “novel social experiment” I will provide some baseline comparison information (from America’s Health Rankings). The curremt rankings of these two engines of experimentation are in parentheses. Let’s look back in five years, to see what’s changed.

  • Overall state rankings
    • Mass (4)    AL (45)
  • Cancer Deaths
    • Mass 191 deaths per 100K (24)  AL 214 deaths per 100K (44)
  • Cardiovascular Deaths
    • Mass 231 deaths per 100K (6)  AL 330 deaths per 100K(46)
  • Diabetes
    • Mass 8% adult population (6) AL 11.8% Adult population (46)
  • Early prenatal care
    • Mass 87.5% pregnant population (2) AL 78.7% Adult population (23)
  • Infant mortality
    • Mass 5.1 per 1000 live births (5) AL 8.9 per 1000 live births (48)

The New England Journal of Medicine published a nice article on the constitutuionality of the Affordable Care Act. In it, there is a lot of information regarding the rhetoric versus the reality.

On the possibility of repeal

However, legislation that overturns the ACA has no chance of becoming law during the next 2 years; in the short term, congressional repeal is a symbolic cause, rather than a realistic possibility

On the politics of repeal

Pushing for repeal nonetheless allows Republican congressional leaders to assuage their conservative base. But it also represents a risky political strategy. Overturning the law would effectively deinsure 32 million Americans, deregulate the insurance industry, strip insured persons of coverage protections and enhanced benefits, and worsen the projected federal budget deficit – all while the number of people without insurance gallops upward, along with premium prices. A campaign to repeal health care reform could enable Democrats to paint Republicans as doing the bidding of the insurance industry.

Where things stand now

Moreover, parts of the ACA have already gone into effect. Repealing the entire bill would mean that some Americans would lose benefits – including insurance reforms that allow parents to keep children on their plans until the age of 26 and that prohibit insurers from imposing lifetime limits on coverage.

On the mandate

Most legal scholars believe that the mandate is constitutional, and another federal judge in Michigan agreed in a recent ruling.

Why the law seems unpopular

The dilemma for reformers is that too many Americans believe in controversial provisions of the law that don’t exist, such as the imaginary “death panels,” whereas not enough Americans are familiar with or identify as part of the law popular provisions that are real, such as enhanced Medicare coverage of preventive services and new consumer protections for Americans with private insurance.

Why it will likely succeed

Government health insurance programs, once they are in place, often prove enormously popular regardless of the controversy surrounding their enactment; Medicare is an important case in point. The ACA may yet overcome partisan polarization, its amorphous structure, and public skepticism and thereby follow a similar course. But for that to happen, the law’s key provisions must first be fully implemented.

So what is going to happen? As I told a group this past week, the real problem is trying to provide seamless coverage so that folks who develop an illness are not left dying in the street because everyone tries to dodge responsibility for paying for the care required.  Senators from Massachusetts and Oregon have proposed a revision to the Act that would allow states to opt out if they can demonstrate their plan offers equivalent coverage to that required by the  Affordable  Care Act. As a person living in a state that continued building schools intended for a single race for at least 15 years following “Brown vs the Board of Education of Topeka,” I would like to see how they will determine equivalency before I feel good about revision. Let’s move ahead.