Health Reform: Power to the States?

During my lifetime, I have lived, practiced, or owned homes in Iowa, Kansas, Missouri, Tennessee, North Carolina, Minnesota, Florida, Massachusetts, and Connecticut. Perhaps that is why I am sensitive to regional variations, diverse cultures, and present health care trends, as exemplified in the states.

One of these trends is the prospect of return of health care power to the states.

• The constitutionality of the individual mandate, now being considered in Atlanta among three judges of appeal courts is a state issue. Does Obamacare exceed the “enumerated powers” of the federal government? Is Obamacare about facilitating commerce among states or is it about imposing taxes? These are not trivial questions, since 26 states have joined in the suit against what they consider to be a Washington power-grab.

• The political movement to issue block grants for Medicaid management to the states so they can determine their own Medicaid programs is a powerful challenge to Obamacare. Should Medicaid recipients beholden to the wishes and the culture of state residents or to the demands of remote elites in Congress and the CMS establishment, who may be far removed from realities in the states?

• The crux of the health care debate is about state versus federal power. The Obama administration feels centralized government has the power to impose mandates and taxes on the states, even if these mandates and taxes threaten individual liberties or state budgets. To a limited extent, the administration has gone along with the states by offered temporary waivers to a handful of states for relief from Obamacare until 2014.

Obamacare is enough to make the Teapots of the Tea Party boil with talk of taxation without representation and "taking back our country". On the other side, the question is. Shall we hang together or hang separately – united we stand, divided we fall - and so forth and so on.

Much of this debate is playing out politically in the presidential campaign, now underway. Mitt Romney, former Massachusetts governor who oversaw so-called Romneycare, said to be the model of Obamacare, is at the center of the state versus federal dispute. Romney’s present position is that each state ought to have the option of developing its own health care system, depending on the wishes of its citizens. If Massachusetts and Vermont want universal coverage or a single-payer system for their citizens, so be it. If a conservative state like Utah, which voted 78% Republican in the last presidental election, embraces market-based approaches, let it be.

Candidate Romney now says he will immediately push for Obamacare repeal should he become President. This, of course, could prove to be administratively awkward since Washington-based Medicare and Medicaid experts prefer an unified approach and since 20% of Americans move each year, often to other states.

Watch the states. That is where the action is. Read Physiciansfoundation. org. The Physicians Foundation represents doctors in state medical societies. These societies closely mirror what practicing physicians think, and they will be held responsible for carrying out Obamacare mandates and rules. A Physicians Foundation survey found 67% had a "somewhat"or "very negative" reaction to the new law, and 93% said the new law will force them to stop seeing or restrict the number of Medicaid patients they see, and 87% said they would close or restrict Medicare patients. Results of an athenahealth and Sermo survey in April 2010 were even more ominous; 79% were pessimistic about the future of medicine, and 66% said they consider dropping out of government programs.

The states are where the greatest resistance to PPACA will be. The heaviest expenses will fall upon the states, not only in caring for 34 million more Medicaid recipients, and probably millions more, but in setting up health exchanges and other machinery necessary to carry out government mandates. The states are waiting to see if the courts will declare PPACA unconstitutional, many are delaying action as long as possible, and a few, like California, are moving forward.