The Robesonian (Lumberton, NC) November 13, 2019 Commentary
RALEIGH
— When the Democratic Congress and the Obama administration enacted the
Affordable Care Act a decade ago, the part that got the most attention was a
set of insurance exchanges where Americans could enroll in private health plans
with varying degrees of subsidy.
It made
headlines when most states chose to use the federal insurance exchange rather
than setting up their own. It made more headlines when the federal-exchange
website initially crashed.
Meanwhile,
because the plans would be highly regulated, and thus highly expensive, the
ACA’s framers believed it necessary to compel relatively young, relatively
healthy people to buy the overpriced plans in order to keep the insurance pools
from imploding. So despite candidate Barack Obama’s opposition to a federal
insurance mandate, President Obama signed one into law.
Lawsuits
ensued, producing still more headlines. A majority of justices of the U.S.
Supreme Court concluded that the mandate was unconstitutional, but Chief
Justice John Roberts preserved it by redefining it retroactively as a tax.
Later, a Republican Congress rescinded the tax.
It’s
not hard to see why many Americans still consider “Obamacare” to be primarily
about government-subsidized private plans. But it never was. From the start,
the Affordable Care Act was mostly about expanding Medicaid. That’s where most
of the increase in health-plan enrollment was intended to occur.
For
most progressives, the ACA is merely a waystation. They believe America ought
to adopt a single-payer, government-run system. Some explicitly advocate
Medicare for All. Others are pursuing a gradualist approach — get all states to
Medicaid expansion, then expand Medicare to near-retirees, etc. — but with the
same ultimate goal.
Most
conservatives reject this goal, fully and fiercely. Most Americans do, too,
when they come to understand the full implications of the idea. Rightly or
wrongly, they think of Medicare as a retiree health benefit for which they pay
throughout their working lives. They don’t see it as welfare. And during their
working lives, most are satisfied with their private health-care arrangements.
They
suspect that if the federal government had full control over the financing of
medical services, the quality and availability of those services would suffer.
They are right.
Among
other worthy objections to a single-payer system, I am partial to the
federalist one. Why should America have a single approach to financing health
care? In addition to its dubious constitutionality, such a policy prevents
different states from pursuing different strategies in response to different
circumstances and the preferences of their citizens. After all, “Europe” has no
single-payer plan. Separate European countries, most with populations
comparable to American states, have adopted their own systems. Some have,
indeed, set up government monopolies. Others use a mix of public and private
providers.
As a
conservative, I see a great deal of merit in letting states go their own way
here, both with regard to financing care and to regulating providers. The
problem has always been how to get from here to there. As the North Carolina
General Assembly contends with yet another push to embrace Medicaid expansion,
I think it wise not just to say what we are against — putting hundreds of
thousands of additional North Carolinians on welfare — but to say what we are
for.
A good
place to start is a proposal from the Health Care Consensus Group, a network of
market-oriented health reformers from across the country. It would convert
federal funds for Medicaid, health exchanges, and other programs into consolidated
grants. State governments could use the grant funds in multiple ways, including
traditional Medicaid, premium support for private plans, insurance pools for
high-need patients, health savings accounts, direct primary care, and public
clinics. State legislators and governors who want to go all the way to
single-payer could do so but they’d have to enact the additional taxes and
expenditures required themselves — and defend their choices in state elections.
Democrats
and Republicans have been debating health care reform for decades in
Washington. It’s the wrong location. And which national plan to adopt is the
wrong question.
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