Progressives and the states
Ed Kilgore takes on an interesting question in light of this piece by Scott Lemiuex about the Supreme Court's Medicaid expansion decision. He asks whether partnering with the states is in line with progressive values in the first place.
Recall that the major purpose of the Medicaid expansion itself (as has been the case in a host of previous federal “improvements” to Medicaid) was to reduce the vast disparities in Medicaid coverage in the various states, a major source of the “uninsured” problem to begin with. Is the real offense to progressive values the enhanced ability of states to reject federal limitations on their control of Medicaid policies, or the original structure of Medicaid giving them that control in the first place? Certainly the decision to make a Medicaid expansion a key element in ACA was attributable in part to the desire to build on the most important existing program providing health insurance to those without meaningful access to private insurance (or to Medicare or VA), and in part to reduce, albeit not by that much, the federal costs associated with covering the uninsured. But as some state-level progressives have been arguing for decades, the continued reliance on federal-state programs to address national policy objectives comes at a considerable price of its own: the inevitable interstate inequities, a loss of accountability, and public confusion as to which level of government a central public function “belongs.”
As regular readers know, I’m personally not sold on a single-payer system (though I’m increasingly attracted to it), and don’t think just expanding Medicare to cover everybody necessarily makes sense or is the political silver bullet its proponents often assume it is. But the eventual goal of getting rid of the current patchwork system of government health insurance programs ought to be pretty fundamental to progressives. Would anyone designing a universal national system of health insurance (whether it’s single-payer or public-private) assume it was a good idea to make state governments central to its administration? Maybe, or maybe not. But the Court’s decision ought to make us reconsider whether the crutch of intergovernmental programs, so often utilized for short-sighted reasons, really ought to be the central instrument of progressive governance.
Indeed it should. I think this is one of the most important issues for American progressives to start thinking about as we try to formulate how best to proceed in the 21st century. My feeling is that the patchwork quilt of the American system in general is an anachronism. At the time the nation was formed, and even until fairly recently, this country did operate on a state and regional basis, both culturally and politically. I think that's changing (even though the lines remain similar.) And I think we should get over this idea that these so-called sovereigns are necessary as "partners".
More importantly, I think it's worth fighting for the idea that this kind of inequity is morally wrong. We're all Americans, whether from Mississippi or Vermont, and continuing this charade that we are so "different" culturally that it's wrong to expect that people be treated equally regardless of what sub-state in which they happen to live is frankly disturbing.
Now, I'm certainly not saying that progressives shouldn't take what they can get when it's possible. If California comes up with a better plan, I'll take it.(And with the way we are currently structured, it's our best hope for a better system for all.) I'm specifically talking about this practice of federal laws and programs being relegated to the states for implementation, in which some states choose to deny their own citizens in order to make a point and we all behave as if the order that this be so came down from Mt Sinai. And after all, while the federal government is a cesspool of corruption and inefficiency, it's nothing to the petty, second rate, cheaply bought (often term-limited, resume-building) lackeys at the state level.
I think if the program is for all Americans it should be implemented the same way in all of America. This notion that each state has unique "cultural" requirements is nothing more than a cover for the fact that a certain group of people still haven't accepted that this is one country.