Tuesday, February 13, 2007

More Federalism For You

I'm for some reason always pleased to see my work crop up in the popular media, even if the framing is off.

From the NY Times:

States and U.S. at Odds on Aid for Uninsured

In the absence of federal action, governors and state legislators around the country are transforming the nation’s health care system, putting affordable health insurance within reach of millions of Americans in hopes of reversing the steady rise in the number of uninsured, now close to 47 million.

But the states appear to be on a collision course with the Bush administration, whose latest budget proposals create a huge potential obstacle to their efforts to expand coverage. While offering to work with states by waiving requirements of federal law, the Bush administration has balked at state initiatives that increase costs to the federal government.

The National Conference of State Legislatures has reported: “Health care reform was hot in legislatures across the nation in 2006, and the forecast for this session may be even hotter. Fueled by the increasing number of uninsured Americans, the declining number of employers offering insurance to their employees, the improved fiscal conditions in the states and the lack of federal action, states are leading the way in health care reform.”

Knowing they cannot count on a major infusion of federal money, some states are looking to their own revenue sources, including tobacco taxes, pools of money set aside for charity care and uncompensated care, and assessments levied on employers who do not provide health benefits to their workers.

State efforts face several potential pitfalls. The cost of coverage could spin out of control. An economic downturn could reduce states’ fiscal capacity. Moreover, a federal law, the Employee Retirement Income Security Act of 1974, could block any state program that requires employers to alter their health plans.

In Washington, health policy debates highlight the ideological divide between Republicans and Democrats over the proper role of government in helping the uninsured. Governors and state legislators tend to be more pragmatic.

Mr. Bush’s efforts, combined with the flurry of state activity, have forced Congress to face fundamental questions about the Children’s Health Insurance Program: If states run out of money, should the federal government bail them out? Should states be allowed to use the money to cover adults?

Interesting stuff. Among many other bratty, ill-considered positions, I used to consider myself a "21st Century New Dealer." Seriously. I wholeheartedly believed that a strong centralized government was the best authority to implement "good" public policy goals at a nation-wide level, and there was nothing to replace the imprimatur of authority and efficacy of enforcement that comes with federal action. Now I kind of know a little better. There is a dynamic and mutally constitutive relationship between the states and federal government. With the rise of the adminstrative state in which we are governed more by agencies and regulatory rules than legislatures and laws, there is a blurred line between state and federal government. In absence of federal action (see above) states are indeed "creative labs" of legislation, stepping in to regulate behavior that the federal government can't reach or enacting more far-reaching statutes than the federal government is willing to (particularly in the areas of environmental regulation, family and medical leave, pregnancy discrimination). So it's a lot more complicated than I thought when I was in college. Thank goodness.

The article highlights many interesting issues--how state initiatives can run into the problems of the federal budget, but I wouldn't say that they're "at odds" per se--but this administration in particular is frustrating the efforts of the states to extend coverage to adults. So much for states' rights rhetoric! Also interesting, though it isn't gone into in depth, is the potential for the Federal ERISA statute to preempt states' attempts to enact "play or pay" Big Box rules for empoyers of over 500--either these employers (i.e. WAL-MART) provide health insurance for their employees or are fined for non-compliance. Such play-or-pay rules likely run into preemption problems, as ERISA already has its own mandates about the provision of benefits by employers. So there are definitely some interesting constitutional issues here in addition to the general structural questions about the proper role of the statse vis-a-vis the federal government.

Federalism for you.