Perhaps the only thing as contentious as the process to pass health reform has been the battle over its implementation. In the midterm elections, repeal took center stage, but the fight in the courts has been more prominent and has focused sharply on the individual mandate, viewed as the weakest link in the chain. Is it constitutional or isn’t it? Just over a week ago, another federal judge upheld health reform. As Jonathan Cohn writes, that makes the score 3-2 in favor of constitutionality. If you weren’t quite up on that score, if you thought the judges so far had found the individual mandate unconstitutional, blame lop-sided media coverage. Still, it doesn’t matter, because it all comes down to the Supreme Court, and let’s just say that precedent ain’t what it used to be.
But the Obama administration hasn’t played all their cards yet, and they just laid another one on the table this week. Specifically, President Obama has come out in support of an amendment to the Affordable Care Act that lets states opt-out of the various mandates that are so contentious. That is, they don’t have to participate in the insurance exchanges, don’t have to adhere strictly to federal minimum benefit packages, and their residents don’t have to comply with an individual mandate.
There’s just one catch: To opt-out, states have to demonstrate that they can design a better alternative. That means that they have to cover as many people in their state as the ACA would, that this coverage would be comprehensive and affordable, and that the state plan would not increase the federal deficit. Meet that three-part test and you’re on your own.
It’s a politically brilliant move, and I like that it wasn’t done right out of the gate. This gave states time to complain about all the things they don’t like, which makes giving them the opportunity to address these concerns themselves much more significant. I also think it makes sense. Just like the Medicaid program has flexibility, a one-size fits all approach to reform isn’t necessarily ideal in a federal system like ours. That said, do I think the states will be able to design and implement a better system than that proposed by the ACA? I’m not sure, but I am hopeful that they can. After all, the states can be very useful laboratories if we’ll just take advantage of them. This just puts the ACA in place as a safety net, that will ensure that states do right by the people who live in them.