Obama Endorses State Flexibility (to Implement Single-Payer Health Care Systems)

President Obama may have a reputation as being somewhat cool and detached, but he seems to work fairly hard to come across as a good listener. And he wants the heads of America's state governments to know that when it comes to his health health care overhaul, well, maybe he hasn't felt their pain, but he has heard about it. At a speech to a gathering of state governors today, Obama said that he's aware that there's some antipathy toward the Patient Protection and Affordable Care Act. Via Marc Ambinder:

"I agree with Mitt Romney, who recently said he's proud of what he accomplished on health care in Massachusetts and supports giving states the power to determine their own health care solutions."

First, a word of advice: When talking about health policy, it's usually advisable to avoid starting any sentence with the words "I agree with Mitt Romney." (Granted, in this case we probably shouldn't be surprised; the White House has made no secret about its affinity for the health care overhaul signed into law by Romney during his tenure as governor of Massachusetts.)

But lets move on. What is this newfound state "power" Obama speaks of? Why it's the power to request permission (how kind! how generous!) to opt out of the health care overhaul's individual mandate and federally-mandated insurance requirements…by proposing slightly different ways to meet those same federally imposed coverage and benefit standards. Apparently, if states can find different ways to screw up their health systems in roughly the same way that the PPACA already outlines, Obama will be happy to let them try.  

Which is to say that the proposal endorsed by the president, originally put forward by Senators Ron Wyden and Scott Brown, leaves very few plausible options for state governments seeking to experiment. Perhaps some states could find alternative ways to achieve a similar effect to the individual mandate, but those states would still be in the position of having to find some way to coerce individuals into purchasing health insurance that met the law's minimum requirements. That's not much of a change.

Indeed, if you're looking for potential changes, you should look elsewhere. There's no option to opt out of the budget-busting Medicaid expansion, no option to ditch the exchanges or many of their minimum coverage requirements, no option to fold multiple existing state-level health care programs into the permission request. About the only significant choice it seems to open up is whether to ditch the PPACA's government-run insurance exchanges and go directly to a state-run single payer plan—which is exactly why Vermont's fun-lubbin' socialist senator Bernie Sanders is so fond of the idea.

Arguably, it doesn't even add anything new to the law; all it does is back up the date at which states can ask for waivers. The law already allowed states to look for these alternatives starting in 2017. Under the Wyden-Brown proposal that Obama endorsed today, that date would change to 2014.

So my criticism of the proposal now remains the same as when it was first announced last November: It provides a curious form of flexibility: the kind that only bends one way. Obama, in other words, wants state governors to know that he's heard their complaints about the lack of state-level flexibility. But he doesn't seem interested in actually doing much to help them.