Many of our state governments, Republicans and Democrats alike, are trying to provide health insurance for the 10-20 percent of their residents who have none. They have accepted this increased role because they know what they have isn‘t working--and because their voters and health care providers are letting them know it.
Also, most governors and state legislators believe they can do a better job of providing health care access to their residents than the federal government. And, finally, because they believe, with cause, that as long as there are Republicans in Congress, we will not have a national system.
State efforts deserve praise, but I believe they are outbound on an impossible journey. First and foremost, they have very little chance of raising the big bucks they need because of a fact of life inherent in a system of 48 contiguous states.
To provide universal access to health care, states have limited choices. To do it they would have to enact employer or individual mandates or levy taxes so severe they would drive businesses and residents from their state. Kansans in the absence of similar taxes and mandates in Missouri would be heading east.
(Only Hawaii has successfully mandated employers provide employees with health insurance. But to flee, they have to walk a long way on water.)
States are also in trouble because they not trying to establish a universal system for all their residents, but rather they are trying to just plug holes. They intend to buy or supplement the cost of private health insurance for the poor and near-poor.
This is an immediate administrative nightmare, because those eligible for help this month may not be next month. Incomes change, particularly among the near poor..
Also, most states intend to turn millions of people over to often poorly regulated private insurance companies that are in fact beyond their regulation because of a 1974 federal law called ERISA limiting state regulation, and a 1940s law requiring state, not federal, regulation.
Sending more money to private health insurance companies is like pouring gasoline on an already raging fire. Private companies have at least three times the administrative costs of public administration. Throw in high profits and immensely excessive executive salaries, and state money will not go far.
But that does not mean states should give up, nor we should not be happy about their sensitivity to the problem of our nation‘s miserable health insurance system. States can be effective administrators more responsive to people’s needs than the more distant federal government.
And with something so critical as medical care, one size does not fit all. Some people in Kansas will always be farther from even the best planned emergency medical services than anyone in Rhode Island.
If we didn’t have states, we would have to invent them. So let’s take advantage of their present enthusiasm to bring American health care into the 20th and 21 st century by establishing the federal financing and regulation necessary to make a state-based system work.
What’s needed for a state-federal system?
First of all, there must be federal financing dependent on participating states meeting legislated basic requirements. Federal money can also help poorer states to achieve systems comparable to those of wealthier states. Medicaid already works this way.
Along with substantial national financing, there would need to be regulations defining a benefit package, accessibility, portability and other factors necessary in the federal system of a nation with a 14th Amendment.
I recognize “Medicare for All,” an all federal program, is a reasonable alternative. What is not reasonable is to continue what we are doing, or any minimal modification of this failed system.
For example, if we continue our historical increases in health care costs of 9% each year (for 30 years), and our gross national product increases an ordinary 3 % per annum, in 24 years we will be spending $16 trillion for health care out to a GNP of $24 trillion, just two of every three dollars.
And we may still be 42nd among nations in longevity.
Dr. Roy may be reached at firstname.lastname@example.org