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Posted at 12:11 PM ET, 11/18/2010

Have Scott Brown and Ron Wyden figured out the way forward on health care?

By Ezra Klein

Thumbnail image for brownbanking.JPG

The GOP’s slogan on health-care reform has, till now, been “repeal and replace.” But they don’t have the votes for either. What they might have the votes for is reform that, maybe, one day, if all goes well, could lead to replacement. And, believe it or not, liberals might be able to get on board with this strategy, too.

This morning, Sens. Ron Wyden (D-Ore.) and Scott Brown (R-Mass.) introduced the “Empowering States to Innovate Act.” The legislation would allow states to develop their own health-care reform proposals that would preempt the federal government’s effort. If a state can think of a plan that covers as many people, with as comprehensive insurance, at as low a cost, without adding to the deficit, the state can get the money the federal government would’ve given it for health-care reform but be freed from the individual mandate, the exchanges, the insurance requirements, the subsidy scheme and pretty much everything else in the bill.

Wyden, with the help of Sen. Bernie Sanders (I-Vt.), was able to build a version of this exemption into the original health-care reform bill, but for various reasons, was forced to accept a starting date of 2017 -- three years after the Patient Protection and Affordable Care Act goes into effect. The Wyden/Brown legislation would allow states to propose their alternatives now and start implementing them in 2014, rather than wasting time and money setting up a federal structure that they don’t plan to use.

In general, giving the states a freer hand is an approach associated with conservatives. On Wednesday, Sen. Orrin Hatch (R-Utah) sent a letter to the Republican Governors Association advocating exactly that. “The most effective path to sustainable health care reform runs through the states, not Washington,” he wrote. If it’s really the case that the states can do health reform better, Wyden and Brown are giving them a chance to prove it.

One state that wants to prove it is Sanders’s Vermont. “As a single-payer advocate,” he says, “I believe that at the end of the day, if a state goes forward and passes an effective single-payer program, it will demonstrate that you can provide quality health care to every man, woman and child in a more cost effective way. So I wanted to make sure that states have that option.” Vermont’s governor-elect, Peter Shumlin, is on the same page. “Vermont needs a single-payer system,” he said during the campaign.

Single-payer, of course, is even more objectionable to conservatives than the existing health-care law. But that’s the beauty of this option: It allows the liberal states to go their way, the conservative states to go their way, and then lets the country judge the results. If Vermont’s single-payer system provides universal care at a low, low cost, then maybe that nudges California -- which is facing massive budget deficits -- off the fence. After all, if the state spends less than the government sends it, it gets to keep the remainder. It’s a nice incentive for cost control. And if it works, how long will more conservative states wait before they decide to take part in the savings, too?

But conservatives don’t believe that will happen. They think a consumer-directed system will offer higher-quality health care at a lower price, and with more choice. If Tennessee takes that route and outperforms Vermont, it’ll be their system that spreads across the land.
The funny thing about the health-care reform debate is that for all the arguing, everyone says they’re in favor of it. The GOP’s "Pledge to America," for instance, promises that the Republicans will repeal Obama’s health-care law “and put in place real reform.” Shumlin, too, promises Vermonters that he’ll produce “real reform.” The problem is that no one seems able to agree on what real reform is. The beauty of Wyden and Brown’s approach is that the country doesn’t have to choose.

“Real reform,” in their world, is whatever works best to cover everyone at the lowest cost. Utah and California can go their separate ways, and the other states can judge the victor based on results, not ideology.

That an Oregonian and a Bay Stater are behind this legislation is perhaps no surprise: Wyden’s home state of Oregon just reelected John Kitzhaber, a former emergency-room doctor who pioneered a radical set of Medicaid reforms when he served as governor in the late '90s and early Aughts. Brown’s constituents in Massachusetts still overwhelmingly support the system that then-Gov. Mitt Romney signed into law in 2005 -- and that then-state Sen. Scott Brown voted for. “There’ve been a handful of states that’ve tried for some time to break out from the cookie-cutter molds,” says Wyden, and their senators want to protect their innovations.

The Obama administration is cautiously supportive. "The cliche about states as the laboratories of democracy is not just a cliche," CMS director Don Berwick told Wyden at a Finance Committee hearing. "It’s true." The question is whether the rest of Congress will agree. Liberal Democrats might shiver at the thought of conservative reform plans, while conservative Democrats might worry about the possibilities of public options and single payer. Republicans may worry that attempts to reform the health-care law will read to their base as if they’re making peace with it rather than working to repeal it. And both sides will face pressure from various industries involved in the provision of medical services that fear -- and will likely fight -- the prospect of reforms they can’t anticipate, and may not benefit from.

But those who hide from this proposal are fundamentally signaling a lack of faith in their own ideas. What Wyden and Brown are offering is the chance for the various sides to prove that they’re right. If the industry players make the system work better, then the states that prize their involvement will prosper. If conservative solutions are more efficient, that will be clear when their beneficiaries save money. If liberal ideas really work better, it’s time we found out. Forget repeal and replace, or even reform and replace. How about compete and succeed?

Photo credit: Lauren Victoria Burke/AP.

By Ezra Klein  | November 18, 2010; 12:11 PM ET
Categories:  Health Reform  
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Comments

--*If Tennessee takes that route and outperforms Vermont, it’ll be [...]*--

Just one socialist endeavor against another.

States should be free of federal directives in such regards, completely.

Posted by: msoja | November 18, 2010 12:17 PM | Report abuse

Call everybody's bluff? That's change I can believe in.

Now I normally like the generic liberal dog in a fight. But Brown, a guy who breaks liberal hearts by getting elected, then proceeds to offer bi-partisan substance instead of collecting a paycheck? That's dog I'll root for any day.

I guess all those Mass voters were right.

Posted by: BHeffernan1 | November 18, 2010 12:23 PM | Report abuse

Call everybody's bluff? That's change I can believe in.

Now I normally like the generic liberal dog in a fight. But Brown, a guy who breaks liberal hearts by getting elected, then proceeds to offer bi-partisan substance instead of collecting a paycheck? That's dog I'll root for any day.

I guess all those Mass voters were right.

Posted by: BHeffernan1 | November 18, 2010 12:26 PM | Report abuse

Of course, isn't the end result supposed to be helping people obtain better healthcare? So those of us stuck in states that institute lousy systems get to suffer and those of us who happen to live in Vermont prosper? It's not like we can all just pick up and move to Vermont or the state with the healthcare system we prefer. Plus, doesn't single-payer rely on having a large pool of people spreading the costs and risks? Is Vermont large enough to make it work?

Posted by: AuthorEditor | November 18, 2010 12:33 PM | Report abuse

Mass is broke and even Mr Brown knows that.

Posted by: obrier2 | November 18, 2010 12:33 PM | Report abuse

This is a great idea. It's amazing what a little Republican drubbing in the Bay State can accomplish (don't think Brown's got in mind an uphill fight in 2012?).

I've long had the notion that something like this could have been a perfectly reasonable approach to universal health care in the first place. What if Congress from the get go had simply passed a law saying "a state must enact reach 95% coverage by January 1st, 2017 in order to continue receiving healthcare funding from the federal government."

Still, I don't predict the new legislation will be successful, for the simple reason that, although it frees states to innovate, it nonetheless binds them to the goal of universal coverage. That goal itself is objectionable to the Tea Party/Ayn Rand crowd, most of whom oppose the notion that universalizing insurance is a proper government function. Moreover, preserving ObamaCare via a federalism approach would likewise preserve an important accomplishment for the president -- one he can campaign on in 2012. And we all know THAT isn't consistent with the GOP's principal goal --stopping Obama's reelection.

Posted by: Jasper999 | November 18, 2010 12:36 PM | Report abuse

This is why Republicans opposed HCR so vociferously. This is exactly what it leads to and they have known this all along. HCR as passed earlier this year has a very short shelf life. But it gets the ball rolling and forces Republicans to come up with their own ideas. How many HCR reform plans were attempted 1994-2006? Now we have a follow-on bill not even a year into the existing law.

Then again, this is a classic case of a bill that gets 52 votes in the Senate (all Dems minus Nelson, Landrieu, Lieberman plus Brown) and not even a hearing in the House. Nevertheless, it is out there and probably will be voted on in the next five years.

I've said this before. If HCR as passed this year gets us on a 20-year plan to something that works, then it was a smashing success.

Posted by: klautsack | November 18, 2010 12:45 PM | Report abuse

I'm open to this. Kudos to Scott Brown for finding the right like-minded partner on the other side of the aisle to work with on this.

I only see two problems: One is that letting states all go their own way reduces the potential for economies of scale. That said, the exchanges as they are to be set up will be only at the state level unless states choose to cooperate. I assume that Wyden-Brown doesn't preclude that?

Secondly, does the health reform legislation as it is set those standards for coverage, quality, and cost? Or are those standards set day-to-day by the HHS? If so, there's a big potential for the whole concept to fall apart under an administration who has different views of what those minimum standards should be (or whether they should even exist).

Posted by: vvf2 | November 18, 2010 12:46 PM | Report abuse

This is interesting and I like it. It's almost like Ed.Reform and "Race To The Top." What will NJ misspell this time?

Posted by: Derf_Vader | November 18, 2010 12:49 PM | Report abuse

By the way, anybody know if this legislation could possibly be considered by the lame duck session? I'm guessing not, given how long it takes to get anything done in congress, but it would surely increase the odds of something like this getting to Obama's desk. I can't imagine Speaker Boehner will allow his chamber to pass something that strengthens the commitment of America's public sector to universalizing health insurance, though I hope I'm wrong.

Posted by: Jasper999 | November 18, 2010 12:50 PM | Report abuse

Let's call this "Enron Redux"

If I tried to convince you about any other business in America that the way to SAVE money was to set up 50 different organizations with different rules in each state, you would not buy my business advice.

Furthermore if I told you in any other area that I expected 50 different sets of people making about $75,000 a year on average were going to be able to properly regulate a nationwide industry making billions a year and make sure there were no loopholes to make enormous cash, for the industry, you would be how shall we say skeptical?

However I'm SURE that health care will be the exception.

Posted by: 54465446 | November 18, 2010 12:51 PM | Report abuse

vvf2:
I agree with your first point. It is very pertinent. Second, how long will it take? Will we know(according to what Ezra thinks) in 2 years? 5?

Posted by: Calvin_Jones_and_the_13th_Apostle | November 18, 2010 12:52 PM | Report abuse

--*[A]nd those of us who happen to live in Vermont prosper?*--

Completely unlikely. The Massachusetts disaster is only buoyed along by massive infusions of money stolen from other states by the Feds. With every state fending for itself, that nipple gets pulled.

Posted by: msoja | November 18, 2010 12:53 PM | Report abuse

I agree. If the state wants a robust public option then it should get a robust public option.

Posted by: maritza1 | November 18, 2010 12:56 PM | Report abuse

Vermont (with all due respect to Bernie Sanders, and I do respect him enormously) may not be exactly the perfect test case for a state health-care plan. The total population of the state is a mere 621,760, it has no major urban areas, is 96.2% white, and has a lower poverty rate than the rest of the nation. While I'm not sure what the implications for a successful single-payer system in Vermont might be, I am left wondering whether a Vermont plan would be easily replicable in high population states like California, New York, Illinois, or Ohio. That said, I say Vermont should definitely go for it.

Posted by: JJenkins2 | November 18, 2010 12:59 PM | Report abuse

Brown must not remember what happened to Bob Bennett.

Posted by: SteveCA1 | November 18, 2010 12:59 PM | Report abuse

This is way too reasonable, common sense and bi-partisan for the TeaGOP folks to ever support it.

Posted by: vintagejulie | November 18, 2010 1:07 PM | Report abuse

*****Brown must not remember what happened to Bob Bennett.*******

Um, I think rather more likely is that Brown remembers what happened to EVERY SINGLE Republican nominee for state-wide office in Massachusetts this moth. Yup, they all lost, from Governor on down to State Auditor.

Brown's toast in 2012 unless he immediately starts building a reputation as a quirky, mavericky, refues-to-lick-the-boots-of-the-Tea-Party kinda Republican. Massachusetts ain't South Carolina.

Frankly, Brown's got a better shot running as an independent in 2012 than tacking hard to the right to insulate himself from a Tea Party nomination challenge. He'd have a decent shot at winning a three way race if his popularity remains high. He'd have zero shot in a general election against a Michael Capuano or Vicky Kennedy if he's reincarnated himself as Rand Paul just to stave off a challenge from his right.

Posted by: Jasper999 | November 18, 2010 1:11 PM | Report abuse

This is, more of less, the way the Canadian health care system works.

Posted by: redjacket | November 18, 2010 1:12 PM | Report abuse

The standard critique of state-based systems, going back a long way, is that when they're most needed -- particularly during times of rising unemployment -- state treasuries lack the economic tools available to the feds. Ezra wrote about this in 2007:

http://www.washingtonmonthly.com/features/2007/0707.Klein.html

Now, as Ezra wrote in March, state innovation in the context of a federal backstop is a different matter, but as 54465446 notes, it's a potential regulatory nightmare. There's also the small matter of accountability and overall stability: state governments are not exactly cradles of effective representative democracy -- compared to, say, the provincial governments that implement Medicare across Canada.

Posted by: pseudonymousinnc | November 18, 2010 1:13 PM | Report abuse

Isn't there a danger that this will simply lead to states opting out of the individual mandate?

Posted by: mitchquick | November 18, 2010 1:16 PM | Report abuse

54465446-

O.K. I'm going to break my rule of never disagreeing with you.

I disagree.

This reminds me of the push for clean water in the mid-20th Century. They began with a very bad bill (1948 Water Pollution Control Act) and then tinkered until they came up with something a little stronger (1965 Water Quality Act). The states were charged with coming up with their own water quality standards and mechanisms for enforcing them. The states that did best served as a model for the eventual 1972 Clean Water Act. Between 1948 and 1971, virtually nothing changed with respect to water quality, but after 1972, things were dramatically different and better. And it wouldn't have happened without that first bad bill in 1948.

The Wyden-Brown approach is similar in this regard because it allows states to be the laboratories. But, as I said before, this is why Republicans will oppose it.

Posted by: klautsack | November 18, 2010 1:19 PM | Report abuse

All this sounds fine to me. If Vermont wants to go single-payer, and Tennessee wants to go with some market alternative, great.

...So long as most people are covered, it's affordable and providing quality care.

Problem is, we even agree on the principle that all should be covered, or that there's a government role in affordability and quality.

It doesn't get at the old "role of the state" argument that we rehash every generation or so.

The Federal government can lay out some guidelines or benchmarks on insurance coverage and health care delivery, but there will be states and constituencies that fundamentally disagree with any state involvement in health care.

Personally, I'm happy to have some pretty strong federal mandates on coverage, access, affordability and quality. I don't care so much how those mandates are achieved. If there's a federal role in assuring clean air and water, education, and workplace safety, why not health care? If I don't like something, I call my congressman or donate to a cause. That's my view. Others will chafe against any mandate.

One solution would be tying federal money to federal standards. A state can opt to have an 18 drinking age, but they'd lose a big chunk of their highway money.

Many of the states against federal health reform are some of the biggest receivers of federal money, especially vis-a-vis Medicaid. Tie performance to money. Then see if they'll play ball.

Posted by: itstrue | November 18, 2010 1:26 PM | Report abuse

klautsack:

It's not that I think that Wyden Brown is worse than what we just passed. It isn't. It's just that our expectations that it will be somehow better at what we want the system to do are mistaken.

If you really want to save money, you HAVE to go to a nationwide insurance system, and you HAVE to allow for negotiations on prescription drug prices, and you HAVE to allow malpractice reform, and you HAVE to deny payments for things like Provenge, which costs $93,000 per treatment and which extends the life of terminal prostate cancer patients only 4 months on average.

Laboratories have a lot more failed experiments than succesful ones.

Posted by: 54465446 | November 18, 2010 1:41 PM | Report abuse

If this is a no-brainer then why didn't Wyden just put it in the original health reform bill? He was on the committee. I'm thinking we're going to see some opposition from stakeholders in the next few days.

Posted by: bmull | November 18, 2010 1:44 PM | Report abuse

I'm with AuthorEditor - This might be great for those living in "liberal" states, but for me, living in a state that just changed hands from a Dem governor to a Repub gov, I'm not filled with optimism about what my state might come up with.

And, aside from my personal concerns, I just think that a national problem requires a national solution.

Posted by: KarenJG | November 18, 2010 1:47 PM | Report abuse

"Of course, isn't the end result supposed to be helping people obtain better healthcare? So those of us stuck in states that institute lousy systems get to suffer and those of us who happen to live in Vermont prosper? It's not like we can all just pick up and move to Vermont or the state with the healthcare system we prefer. Plus, doesn't single-payer rely on having a large pool of people spreading the costs and risks? Is Vermont large enough to make it work?

"

It's larger than some European countries.


Lefties, please, go for this. I really, really, really like this idea, especially in California.

Posted by: krazen1211 | November 18, 2010 1:51 PM | Report abuse

54465446-

But the point is that some state will come up with this formula and it will become a model. If what you say is true, then it seems like a pretty straightforward mixture of ideas. It's just a matter of getting enough political will to do it correctly. I think when people start considering this on a state level, they'll be more likely to do something creative. Then in 2020 we have another round of improvements to HCR.

Equally important, in my mind, is that you've engaged at least one Republican in a serious effort to address a real problem. By itself, that changes the mentality of this issue.

Posted by: klautsack | November 18, 2010 1:52 PM | Report abuse

Could we end up with a free-rider problem?

Since there's no (governmental) restrictions about moving between States, suppose Vermont goes single-payer - would there then be a great migration of sick people to Vermont?

Posted by: mutterc | November 18, 2010 2:02 PM | Report abuse

bmull, did you read the article? Wyden did get this in the health reform law, he and Brown are just trying to move the start date up.

Posted by: JJ27 | November 18, 2010 2:05 PM | Report abuse

Current health care reform legislation is a starting point for real reform that would have never been set had it not passed Congress and been signed by the President. That is why it was historically significant. It is flawed to be sure, but now real reform is possible as incremental changes reform reform. I like the Weyden-Brown option out as one way to push reform forward -- and an amendment to the current legislation that will make court battles to overturn it tougher.

Posted by: ncccbob | November 18, 2010 2:16 PM | Report abuse

The important thing is that HCR sets the standard for coverage, and states can do whatever they want so long as those standards are met.
i.e. Conservative states can't completely destroy the quality and number of people covered and still receive federal funds.

Posted by: mschol17 | November 18, 2010 2:18 PM | Report abuse

klautsack:

I certainly can't prove that you're wrong, it's just that I think it's the least likely outcome. If you presented this economic model, minus any reference to health care, to most economists, even the ones Ezra loves, and said is this model more or less likely to produce overall savings for the nation, the answer would probably be less.

Posted by: 54465446 | November 18, 2010 2:19 PM | Report abuse

Ezra,

I'm surprised to find you so supportive. I'm thrilled but surprised. The devil will be in the details though. One of the biggest problems with Obamacare was the insistence that the first dollar of health care needed to be paid by someone else. If, for example, the framework allowed states to introduce patient-centric approaches such as mandatory HSA's coupled with catastrophic health insurance, that would be amazing. But if they set the ground-rules so tightly that each state can't help but look the same, its just keeping up appearances.

Posted by: FatTriplet3 | November 18, 2010 2:30 PM | Report abuse

I'll be very surprised if this idea isn't dead on arrival. As someone pointed out earlier, this doesn't look anything like repeal, and I don't think the Tea Party folks are going to swallow it. I don't know, maybe I'm being to cynical. Maybe they'll be able to get a Rick Perry on board to push for it with a "Texas can find a better way!" type of attitude.

Still, if this does pass with conservative support, I don't want to hear about regulatory uncertainty anymore.

Posted by: MosBen | November 18, 2010 2:31 PM | Report abuse

mosben"

You can never have regulatory certainty as a nationwide insurer when you have to deal with 50 or so state incubators. You only make things worse.

Posted by: 54465446 | November 18, 2010 3:13 PM | Report abuse

"patient-centric approaches such as mandatory HSA's coupled with catastrophic health insurance"

Or patient-centric approaches such as single-payer, depending upon what patients consider "centric". That's the wonder of it. (Nice try, though.)

I'm with 54465446, though: even if the federal backstop is a way to address the cyclical issues that Ezra talked about in 2007, the regulatory challenges and economies of scale still matter, and I remain unconvinced that many American state legislatures are capable of tying their own shoelaces.

Posted by: pseudonymousinnc | November 18, 2010 3:38 PM | Report abuse

54465446, I should have been clearer. I meant that I don't want to hear about regulatory certainty from any Republicans that end up supporting this because, as you said, having 50 state incubators is the opposite of regulatory certainty. At this point regulatory certainty is to just let the ACA proceed.

Posted by: MosBen | November 18, 2010 4:02 PM | Report abuse

. After all, if the state spends less than the government sends it, it gets to keep the remainder. It’s a nice incentive for cost control.


Ezra,

How do you think they're going to do that? The only way to limit cost is to limit what is paid to providers and run your plans more efficiently than private insurers. I know single payer advocates like yourself think you can do that but until you actually PAY to set up systems in place do you really think its going to be so inexpensive? What happens when providers balk at Medicare rates or even worse Medicaid rates? What happens when they tell patients that they won't accept the single payer reimbursements and the patients have to pay either the full amount or even the difference? I know you're giddy here about all this but there are so many pitfalls you're not even thinking of.

Posted by: visionbrkr | November 18, 2010 4:43 PM | Report abuse

Here's a thought: Could Vermont offer full reimbursment of medical school loans to any doctor that practices in their single payer system for 5 years? What if they also threw in something on malpractice to make it better for doctors? Is paying for docs to go to school cheaper than paying them more?

Posted by: MosBen | November 18, 2010 4:57 PM | Report abuse

"Here's a thought: Could Vermont offer full reimbursment of medical school loans to any doctor that practices in their single payer system for 5 years? What if they also threw in something on malpractice to make it better for doctors? Is paying for docs to go to school cheaper than paying them more?"


They should be able to do what they want to do.


If California wants to spend money on health care, and Texas wants to spend money on roadways, lets get health care and roadways.

Then measure results 10 years later.

Posted by: krazen1211 | November 18, 2010 5:35 PM | Report abuse

krazen1211-

I basically agree because then we would at least be dealing in facts. My first reaction to this idea is that this is exactly how the law should work - basic backstops provided by the feds with lots of latitude given to states on what to do to get there. This has worked very well in the environmental field and many of the same arguments were at play (minus the death panels, of course). But the sticking point has always been whether there is any role at all for the Federal Government in these things. With HCR, that question is answered. And so the next round of tinkering begins. This is good.

Posted by: klautsack | November 18, 2010 6:29 PM | Report abuse

The problem with this plan is general equilibrium effects. Let's say, for the sake of argument (and just the sake of argument!), that single payer is the best health system, but that it pays providers less than other systems. Then, many of the docs may flee from Vermont for another state. This experiment would imply that Vermont's single payer failed, even though if the whole country tried this, and docs had nowhere to flee to, the single payer would succeed.

State's aren't laboratories when the experimental subjects can jump from one lab to another.

Posted by: allhealthpol | November 18, 2010 8:38 PM | Report abuse

The problem with this plan is general equilibrium effects. Let's say, for the sake of argument (and just the sake of argument!), that single payer is the best health system, but that it pays providers less than other systems. Then, many of the docs may flee from Vermont for another state. This experiment would imply that Vermont's single payer failed, even though if the whole country tried this, and docs had nowhere to flee to, the single payer would succeed.

States aren't laboratories when the experimental subjects can jump from one lab to another.

Posted by: allhealthpol | November 18, 2010 8:39 PM | Report abuse

msoja said, "The Massachusetts disaster is only buoyed along by massive infusions of money stolen from other states by the Feds."

Actually, Massachusetts receives only about 81 cents in federal spending for every dollar it sends to Washington in federal taxes. If MA only broke even in that regard, they could ELIMINATE their income tax and still come out ahead.

The same is true in almost every other blue state. New Jersey, for example, only gets about 60 cents back on the dollar. In contrast, most red states are the beneficiaries of federal largesse. Alaska, that paragon of self-sufficiency, gets about a buck eighty for every dollar it sends to DC.

Please don't just make stuff up.

Posted by: DavidinCambridge | November 18, 2010 9:04 PM | Report abuse

Jasper999 said, "Um, I think rather more likely is that Brown remembers what happened to EVERY SINGLE Republican nominee for state-wide office in Massachusetts this month."

Not to mention what happened in the 40-member state senate. Republican representation therein went from 5 to 4.

And all four of them are running for minority leader!

Posted by: DavidinCambridge | November 18, 2010 9:07 PM | Report abuse

Who defines what coverage gets reimbursements from the Federal government and at what level?

If states can define vastly different coverage for the same number of Federal dollars how is this not a race to the bottom?

Posted by: cautious | November 19, 2010 4:29 AM | Report abuse

"If a state can think of a plan that covers as many people, with as comprehensive insurance, at as low a cost, without adding to the deficit, the state can get the money the federal government would’ve given it for health-care reform but be freed from the individual mandate, the exchanges, the insurance requirements, the subsidy scheme and pretty much everything else in the bill."

Great! Same differance! I'm in California and we pay for all you poor states to do anything antways and I'm OK with that, because I'm a liberal.

Now there is no Party in charge of Congress. Blaming the Democrats doesn’t work anymore so you old or angry frigging Republicans can take a hike now.

If nothing gets done in Congress for the next two years I put the blame solely on the Party of No. Republicans have stalled everything, and won nothing.

Republicans gained the House by telling everyone that they are going to repeal the Heath Care Reform and ban earmarks. Republicans make suckers out of the people who vote for them.

How’s that despair-y, stagnation for you nation?

Posted by: getcentered | November 19, 2010 10:30 AM | Report abuse

Yes! Hooray for the state of my birth and the state where I reside. We, in Oregon, have been making incredible strides towards a new healthcare approach - one that will broaden and improve healthcare. Our governor-elect is an innovator in healthcare [and, might have been tapped by Obama to lead healthcare change but governor-elect Kitzhaber is devoted to changing Oregon's system, first].
One of our biggest stumbling blocks has been the difficulty getting waivers of federal funds so we can use the money in innovative ways. I have worked on healthcare reform in Oregon for several years. The success of the legislators to get this "positive" opt-out [opting out of a specific strategy but only if the results still meet the minimum standards of the federal bill] was a brilliant move. And, the sooner we can start those "experiments" the better. Oreogn is on its way, regardless. This will just make it easier.

Posted by: dcohen3 | November 19, 2010 11:33 AM | Report abuse

Ezra ...

Thanks for the forum.

Implementation is forever.

If interested, there is a very fine article by Drew Altman at Kaiser Family Foundation about the implementation of such an all encompassing and detailed law. The author goes into why, with such a huge change in law, that it's better to go slow over a longer period of time and get it right as we go.

Altman's article was published before the bill was passed and signed into law by the President. Here is the opening snippet as follows:

---begin Altman snippet---

IMPLEMENTATION - Publish Date: 2009-10-08

When I was a graduate student at MIT my adviser Jeffrey Pressman was a great political scientist who had just written the seminal book on program implementation. It was called, simply enough, "Implementation" with a subhead that read: "...how great expectations in Washington are dashed" (OK, we political scientists study politics too much and are a little cynical at times). The book literally created a new sub-field in political science focusing on program implementation. This was one of its major conclusions:

"The great problem is to make the difficulties of implementation a part of the initial formulation of policy. Implementation must not be conceived as a process that takes place after, and independent of, the design of policy."

Jeff Pressman's life ended at too early an age and he was not able to continue this work, but the message is as relevant now as it was when he wrote it in 1973. So how does health reform stack up?

The article continues: http://bit.ly/4mspBu

---end snippet---

A preview of Pressman's book at Google reader: http://bit.ly/cYxv6i

Also, it was Altman I heard at a presentation on this new law and he was explaining what other major nations have gone through over the years after implementing such a grand plan as health care and he ended with the following quote:

"Like other nations we will always be reforming our health care system. In that broader sense, implementation is forever."

Forever... and ever and ever~

Thanks again Ezra.

~OGD~
.

Posted by: oldengoldendecoy | November 19, 2010 12:41 PM | Report abuse

So how come the states haven't done this before now?

Posted by: JRM2 | November 19, 2010 12:51 PM | Report abuse

At last...a couple of senators with some common sense!!

Posted by: dallyllama | November 19, 2010 1:17 PM | Report abuse

.

JRM2 Asked:

"So how come the states haven't done this before now?"

I can only speak for what's happened in the past and is currently happening here in California...

The California State Legislature has twice passed a state-level single payer bill, SB 840, "The California Universal Healthcare Act" (authored by Sheila Kuehl), in 2006 and again in 2008. Both times, Governor Arnold Schwarzenegger vetoed the bill. State Senator Mark Leno later re-introduced "The California Universal Healthcare Act" again in March 2009, newly renumbered as SB 810, and in January 2010, the California Senate passed SB 810. On the last day of the 2010 legislative session, the Democrats pulled SB 810 from the Assembly floor as Governor Arnold Schwarzenegger said he would veto it a third time, with Senator Mark Leno announcing he would reintroduce the bill again in January of the 2011 session.

The California SB 810 measure meets all federal mandates of the Affordable Care Act and could be implemented immediately.

In September, California, was the first state to begin work on an exchange framework as mandated by the Affordable Care Act. The state took the independent agency route in legislation signed by Gov. Arnold Schwarzenegger. The act created the California Health Benefit Exchange and a five-member independent commission to manage it and determine eligibility, enrollment and coverage requirements under qualified carriers.

As of October 25, California's Pre-Existing Condition Insurance Plan that was mandated by the Affordable Care Act became active. The federal government is providing about $761 million to help California operate its high-risk pool until 2014. The pool is expected to provide coverage, coupled with premiums and could accommodate 17,000 to 23,000 subscribers at any given time.

And, on November 2 a waiver was approved by the feds and a $10-billion plan was approved to help California modernize and expand its Medicaid health insurance program for the poor on the basis that the state system is in alignment with the Affordable Care Act.

The state of California will provide a solid basis as a good "laboratory" for the implementation and outcome of the Affordable Care Act.

~OGD~
.

Posted by: oldengoldendecoy | November 20, 2010 4:04 AM | Report abuse

In order to make this system work you still have to have a large enough risk pool. The federal plan, that many are fighting against, is that the flat bellies HAVE to participate to make this work. Imagine if you were allowed to purchase car insurance only after you had an accident. The system would fail. I laugh at double talk when Republicans scream about personal responsibility and then tell a person that all they have to do is show up at an emergency room and they cannot be turned away. Our local hospital is slashing many needed services in response to all of the uncompensated care they have provided throughout our great depression. Michigan entered the recession many years before the rest of the country because of The Big Three and the loss of manufacturing. We turned one of the most prosperous states in to a third-world country. So our local hospital loses $9 million dollars over uncompensated care. We all pay for that in higher premiums and taxes because they bill insurance companies more to cover losses. Only by forcing people to get insurance does any plan work or you will not have an affordable system. Risk needs to be spread out or you will have the same cost prohibitive system that is occurring now. I am the CEO of a health care organization and my premiums, for my employees, have gone up over 140% in a decade. That is unsustainable. Any state that does not address this effectively will get the same failed, bankrupting system that we have occurring now. It makes us uncompetitive and forces manufacturers overseas where wealth is redistributed to a select few rather than nationwide thereby eliminating the Middle Class that support this great nation. We ARE in a race to the bottom. If you allow the private market to address this their response, so far, has been to have a 20% administrative overhead compared to Medicare's 3%. We cannot allow CEO's to be paid 20 - 50 million dollars a year to deny us the product that we paid for. States will have to address this by having single payer options that can run as non-profit entities to keep the costs low. A BIG CHALLENGE but a compromise to the present obstructionist policies. Especially disheartening is all of the seniors that were opposed to health care reform because of selfishness and fear. How quickly they forget when, prior to the Medicare Act of 1965, they had little to support their own health care unless they had a pension that paid for it in retirement. Now they stand in lines denying what they have, to millions of other people. Of course there was a lousy PR sales job that occurred except by the right. I support any plan that forces something other than NO.

Posted by: biker4 | November 20, 2010 9:52 AM | Report abuse

I made a blog post on this subject at the link below:

http://un-thought.blogspot.com/2010/11/how-could-and-why-should-states.html

Posted by: jwogdn | November 24, 2010 2:42 PM | Report abuse

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