ObamaCare: An Experiment in Federalism?

When ObamaCare first passed, most everyone assumed that every state would voluntarily create its own health insurance exchange. The law also required states to expand Medicaid, or face the possibility of severe federal penalties. Neither is true anymore: A majority of states have signaled that they will not create their own exchanges but will let the federal government do it for them. And following last year’s Supreme Court decision, which made the Medicaid expansion voluntary, at least 15 states have said or strongly hinted that they won’t expand Medicaid, while 11 more remain undecided.

Not surprisingly, many of the law’s supporters are unhappy with the lack of commitment: They’re aggressively pushing wavering states to expand Medicaid and build their own insurance exchanges, and shaming the mostly conservative governors who aren’t enthusiastically signing to implement the health law.

I’m not sure they need to be quite so upset. On Medicaid, for example, Aaron Carroll—who, to be sure, thinks states should agree to the expansion sooner rather than later—points out that when the program first came online, it took more than a decade to reach full adoption. Only 26 states participated in the program when it was passed in 1966, and the last state didn’t sign up until 1982. I’m not convinced that ObamaCare’s Medicaid expansion is a good deal for states, as supporters claim; but if it is a good deal, then it will still be a good deal down the road, and holdout states will eventually join in the program.

Similarly, ObamaCare supporters have tried to stoke conservative anxieties about federal power by pointing out that if states refuse to run the exchanges, the federal government will do it for them, thus increasing federal power at the expense of the state. States have responded—correctly—that they don’t actually get that much flexibility or authority under the law, except to follow federal rules, but forget that for a moment: From the perspective of an ObamaCare supporter, would increasing federal power over the law really be so bad? I’d imagine that few of the law’s backers have serious problems with increasing the scope of federal authority over the law, especially when the alternative is to see parts of it set up and run by conservative state officials. Meanwhile, states that opt out now have the option to take over the exchanges down the road: If it’s obviously better to be running—and paying—for these insurance hubs, then states that don’t go for the expansion up front can step in later. (Interestingly, Jonathan Gruber, one of the architects of both RomneyCare and ObamaCare, and a leading proponent of both laws, recently suggested that Florida should let the federal government run its exchange, at least for the time being.)

I’m no fan of ObamaCare, but we’re actually primed for a potentially interesting experiment in health care federalism: Some states will go ahead with full implementation. Others will decline to participate in either the exchanges, the Medicaid expansion, or both. And as a result, we’ll be able to see if it works, and how well. If it's worth doing, states that don't play along now will have clear incentives to do so down the road. 

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  • some guy||

    "I’m no fan of ObamaCare, but we’re actually primed for a potentially interesting experiment in health care federalism: ..."

    Not like this... Not like this. :-(

  • Randian||

    Don't forget that even though the law calls for every single American to prove to the government they are in compliance with the law and it calls for a federal network of exchanges and it attempts to punish employers and individuals alike for noncompliance...Obamacare is NOT, I repeat NOT a government takeover of healthcare. Politifact told me so.

    And even though end-of-life care is extremely expensive and requires difficult decisions to be made by government experts that will decide who lives..."death panels" is a lie. Politifact told me so.

  • SugarFree||

    Never have so many stuck their fingers in their ears and sputtered "LALALALALALA I CAN'T HEAR YOU!" as now.

  • $park¥||

    Sorry, did you say something?

  • sarcasmic||

    requires difficult decisions to be made by government experts

    How are those decisions difficult? It's not like they're deciding the fate of someone they care about, and it's not like government officials or their families are affected by the law anyway. They've got their own government health care plan.

    What do they care?

  • Randian||

    You have to figure out which death is going to cost you votes and lobbyist dollars, sarc. Sheesh, you're such a neophyte to graft and corruption.

    When real currency is no longer in play, only social currency matters.

  • sarcasmic||

    You have to figure out which death is going to cost you votes and lobbyist dollars, sarc.

    In this case you are an unelected bureaucrat who doesn't give a shit about votes and lobbyist dollars.

    The elected officials can throw up their hands and say "It was out of my control."

    You're such a neophyte to how government works.

  • SugarFree||

    Bruce Sterling's Holy Fire

    You can have your youth back, but only if you took no risks and carefully managed your health until you were elderly. The people who consumed the least amount of medical resources were the only ones who could vote, IIRC.

  • ||

    Precisely. John McJohnson of Generic Street, Bumfuck, New Jersey, is just another statistic on a piece of paper for the bureaucrats to decide to death.

    What a fucking abomination these laws are.

  • RightNut||

    We both know John McJohnson of NJ is slightly more likely to get treatment than Whitey O'Southerner of Alabama. One has a higher chance of being a Democrat, so they'll be spared the axe.

  • ||

    Yes. They must cleanse the American population of all those unclean non-Democrats in distant pits like Texas and New Hampshire and Alabama.

    SIEG HEIL!

  • Thane of Whiterun||

    The life expectancy of Ohioans will swing up tremendously.

  • $park¥||

    Is someone about to pull your connection while you're still jacked in?

  • R C Dean||

    The next big case on OCare has been filed in Oklahoma (I believe) and brings the federalism issue front and center. Its the case about whether the feds can impose penalties on employers in states that don't have state exchanges. Reason really should be covering that case, you know. Yeah, I'm looking at you, Suderman.

    If the good guys win, look for a states that have started on their exchanges to quietly drop the project.

  • Sevo||

    "Its the case about whether the feds can impose penalties on employers in states that don't have state exchanges."

    Cato did a briefing on this and also on the competitive advantage going to those who aren't paying the tax.

  • Peter Suderman||

    Right. The state AG is arguing that ObamaCare's subsidies are not available in federally run exchanges (the language of the statute refers only to state-run exchanges). Which may tell you why the law's supporters are so eager to get states to participate in the exchanges: if they lose that case, then the federal exchanges are not going to work very well.

  • Sevo||

    ..."most everyone assumed that every state would voluntarily create its own health insurance exchange."...

    Uh, this "everyone" of whom you write; who would that be?

  • $park¥||

    He's probably talking about all his orange line cosmo friends.

  • ||

    Most people I know didn't. Some blew arteries and shit in fury, and thought their states would never comply. But the federal cock must be caressed. It's the only way to salvation.

  • RightNut||

    To be fair we are always talking about how big and bloated the federal cock is.

  • ||

    Penis reduction surgery is the only way. Libertarian-leaning statesmen are the surgeons, and libertarianism is the scalpel (or chainsaw, if you're in a giddy mood).

  • ||

    It's pretty fucking sad that there isn't a single state government/governor courageous enough to tell the federales outright that they should go fuck themselves -- no state-run OR federally managed exchanges, period. What pussies.

  • $park¥||

    there isn't a single state government/governor courageous enough to tell the federales outright that they should go fuck themselves

    There was a minor scuffle about 150 years ago the outcome of which kinda made this a non-starter.

  • ||

    WBtS comparisons? Really?

    Here's a scenario for you:

    The Texan government issues a long-winded declaration stating, in far more numerous terms: "No exchanges. Absolute noncompliance. Eat shit and fuck off, DC."

    What're the federales going to do? Nuke Dallas?

  • sarcasmic||

    They would have to do something. Anything from cutting off federal dollars to having the governor arrested. But they would have to do something.

  • ThatSkepticGuy||

    "What're the federales going to do?
    "

    Same thing they did when Texas tried to boycott the TSA; withold the Spice.

  • ||

    I'm operating under the assumption that Texas comes into the control of more principled statesmen.

  • Thane of Whiterun||

    Calling it WBtS? Really?

  • ||

    1) My impatience was feigned.

    2) Yeah. No, I'm not a neo-Confederate. :P

  • Thane of Whiterun||

    That's a relief.

    I shudder to think of HampersandR turning into LewRockwellDotCom.

  • RightNut||

    You really think Americans would be ok with Obama calling in the troops to invade say, Texas, for not setting up stupid healthcare exchanges?

  • ||

    As scornful as I am of the federal government and its leadership, I don't think they'd ever go anywhere near that far.

  • sarcasmic||

    I bet they would if Texas tried to secede.

  • ||

    Even then, I'm not so sure. Cuntstain authoritarians in DC depend on apathetic, sociopolitically untuned majorities not to give a fuck too much, or to remain largely unaware.

    If, say, a coalition of constitutionalist politicians were to creep into power in Texas and attempt secession on the basis of liberty, how would Obama's use of military force to subjugate the newly independent republic look to the people among us who'll suddenly start giving a fuck?

    I don't think they'd survive the uproar -- not even the tiniest squeak of the kind of uproar that would surely cause.

  • sarcasmic||

    how would Obama's use of military force to subjugate the newly independent republic look to the people among us who'll suddenly start giving a fuck?

    It would look as intended. Secede and we'll kill you.

  • $park¥||

    To both you and RPA:

    Based on current voting patterns, I suspect many people would think Texas had what was coming to them for daring to stand up to DC. I think if push came to shove, almost every enlisted man and woman from Texas would abandon their post and join their fellow Texans in resisting. Alas, I doubt it will ever come to that. You guys have to acknowledge the fact that this country is on a slow downward spiral and filling up with people who actually want to be cradled in the loving bosom of mother government.

    And besides, don't get your panties in a bunch. I was being semi-facetious.

  • RightNut||

    1. I'm going commando today

    2. I've said several times I think the country is on a downward spiral, and I'm not sure I want to start a family here.

    3. I doubt even Obama's ability to sway morons would get people to accept attacking fellow Americans.

    4. The more likely scenario if a state told the feds to fuck off would be the government withholding money or imposing additional fees on good going to or from that state.

  • ||

    If I may ask, if not here, then where?

  • $park¥||

    3. I doubt even Obama's ability to sway morons would get people to accept attacking fellow Americans.

    The question is, how much are you willing to bet on that. Right now I agree with you, but given another 5 years of these conditions who can know?

    4. The more likely scenario if a state told the feds to fuck off would be the government withholding money or imposing additional fees on good going to or from that state.

    This may induce a sort of siege mentality in the people of Texas. Once that happens, serious calls for secession might start popping up. Then things will start to get real murky.

  • ||

    Murky? This is Texas we're talking about. There'd be Boston Tea Party-style tar-and-feather sessions for IRS officials and shit, dude.

  • $park¥||

    Murky? This is Texas we're talking about. There'd be Boston Tea Party-style tar-and-feather sessions for IRS officials and shit, dude.

    Murky as in does an actual secession war break out? Does the fed just let Texas ride off into the sunset? How much force would be applied to prevent that?

    Texan might go nuts and start lynching fed employees if they felt up to it, but the crazier they get about it the more justified people will see the feds coming in to clean up the mess. By any means necessary.

  • ||

    I guess we'll just have to wait and see.

  • $park¥||

    I guess we'll just have to wait and see.

    Yes. I don't want to be cynical about it either, but it's best to expect and prepare for the worst.

  • ||

    Dude, I know. Don't fucking tell me what to do. YOU'RE NOT THE BOSS OF ME NOW.

    I'm not as cynical as you are, I guess. I still believe.

  • ||

    "filling up with people who actually want to be cradled in the loving bosom of mother government."

    Democracy, eh?

  • RightNut||

    Liberals won't care about the different outcomes in different states and will continually push for one-sized-fits-all federal control.

  • ThatSkepticGuy||

    "Not surprisingly, many of the law’s supporters are unhappy with the lack of commitment: They’re aggressively pushing wavering states to expand Medicaid and build their own insurance exchanges, and shaming the mostly conservative governors who aren’t enthusiastically signing to implement the health law."

    Well, unjust taxation and government finger wagging didn't work. Time to bring out the Gimp.

  • Rick Santorum||

    unjust taxation

    Is our taxes stealing?

  • ThatSkepticGuy||

    Er, EXTRA-unjust taxation?

  • waaminn||

    Sounds like a plan to me dude.

    www.Anon-ids.tk

  • Anton2013||

    Rather than talking about penalties & bad outcome of obamacare people must think of it is for well being of people and we must take benefits of it.
    Medicare Benefits

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