In this op-ed piece, attorney general and Republican gubernatorial candidate Rob McKenna offers his view of the state’s role in implementing the Affordable Care Act. Unlike some in his party, McKenna argues that the law is something the state needs to work with and shape, so that Washington might achieve the goal the feds didn’t – containing health care costs.
The Supreme Court’s decision on the federal health care law’s constitutionality was the most highly anticipated case in decades on the limits of federal power under the Constitution. The ensuing drama will continue to play out in Congress and in the states, and be debated in the media by pundits and Supreme Court scholars alike.
Now that a couple of weeks have passed since the decision, some consensus regarding the ruling is already emerging from an array of commentators, such as Michael Barone. He recently wrote, “The Supreme Court’s decision, while upholding Obamacare, tilts the legal and political playing field away from big government more than anyone anticipated three years ago, and probably for years to come.”
Blocking a massive expansion of federal power under the Commerce Clause was my top priority in joining the states’ lawsuit against the law, followed by our goal of preventing Congress from coercing the states into a mandatory expansion of Medicaid. We achieved both of these goals by not only preventing a serious weakening of our federalist system of checks and balances, but also strengthening the states’ prerogative in a decision where Chief Justice Roberts wrote that the threat to withhold all Medicaid funds from noncompliant states was “a gun to the head.”
These victories of principle have been lost in the subsequent debate over the mandate being allowed as a tax and repeal of the law in its entirety. However, as your Attorney General, my focus has consistently been on such legal principles, and I am pleased our approach has been vindicated.
In Congress, House Republicans have moved to fully repeal the law in a largely symbolic vote. While repeal will be blocked in the Senate, the House GOP vote will send an important message that, as a legislative matter, the debate about how to improve our health care system is not over. Polls continue to show that a majority of Americans of every political persuasion continue to deeply resent a law which was forced through with an extraordinary level of arrogance and pure partisanship.
No one has forgotten former Speaker Nancy Pelosi’s stunning remark that members could figure out what the law contained after voting for it, or her utter contempt for those who raised serious constitutional questions about its individual health insurance mandate and coercive Medicaid funding provisions.
Nor have conservatives forgotten what Rep. Pelosi and likeminded liberals are really aiming for with passage of the law. As the Washington State Democrats’ own chairman bluntly put it when Congress passed the law, “I believe that we will march steadily towards the single-payer system that most Democrats support.”
Furthermore, the Supreme Court’s ruling that the individual mandate’s penalty is a tax shifts the political debate in an unanticipated and crucial way. Neither side arguing the case seemingly anticipated a ruling that upheld the mandate as a tax for constitutional purposes. Many are left wondering, after this ruling, what other activities people are not engaging in for which they can be taxed.
This contradicts what President Barack Obama and congressional Democrats said when arguing for the law’s passage in 2010. The prominent Democrats who insisted the individual mandate is not a tax have some explaining to do to the public.
As all of this plays out, it is important not to lose sight of the fact that our current health care system is unsustainable financially, and Obamacare is likely to make it worse. A highly partisan Congress chose higher taxes and more deficit spending instead of making the tough decisions that would contain costs and set our country on a more sustainable path.
The act remains an unpopular, top-down approach that misses the mark on the most important issue plaguing health care in this country: Cost. This fact is obscured by a relentless insistence by the administration that what really matters is keeping 26-year olds on their parents’ insurance policies. That and other oft-cited provisions, such as eliminating lifetime caps on coverage, probably could have been passed with bipartisan support outside the 2,700 page bill that was rammed through on a straight party-line vote.
Also lost in the spin cycle is the nature of the individual health insurance mandate itself. It is not merely a requirement that every American prove they have some insurance, but a mandate to acquire whatever amount of insurance the government dictates. Want a “catastrophic” policy that allows you to self-insure for the first $10,000 in exchange for lower premiums? Forget about it. You will be required to buy “essential coverage” that forces you to subsidize everyone else.
That flies in the face of what consumers clearly want. The public want choices, not to be locked into the federal government’s approved plans. Pollster Scott Rasmussen recently noted, “By a three-to-one margin, voters believe that increased competition among insurance companies would do more to reduce costs than increased government regulation. Voters also want to rein in the government bureaucrats. Rather than letting the government define a one-size-fits-all insurance plan, 77 percent think individuals should have the right to choose between plans with a mix of higher deductibles and lower premiums or the reverse.”
At the federal level, then, Congress is driving federally-mandated health insurance reform. The act changes the way people think about coverage, but not the cost of care itself. The states will have to address what Washington, D.C. refuses to confront. Indeed, the states are the best place to implement market-friendly policies that give consumers choices and increase competition among insurers. From Olympia to Albany, we need a serious discussion regarding how each state will provide for itself needed reforms that address cost, access and quality of care in a way that works for each state.
Washington state can remain a leader in true health care reform. We can halt the rate of health care inflation which is squeezing government and personal budgets, and keep quality care in reach for more families. We can preserve and expand consumer choices, and even consider a multi-state exchange with neighboring states. Rasmussen’s polling revealed that voters “overwhelmingly believe that everyone should be allowed to buy insurance policies across state lines.” To bend the cost curve, we need new incentives for consumers and providers so everyone benefits from healthy living, coordinated care and better outcomes.
For consumers, we need more people participating in wellness plans, with the reward of lower premiums for taking proactive steps to stay healthy and ward off chronic disease. We should encourage more consumer-directed health plans which feature incentives for cost-conscious behavior like using generic drugs when appropriate and avoiding unneeded tests and procedures. That can’t happen until we have a price-transparent health care market.
For the health care delivery system, it’s time to set up a system that rewards providers for outcomes, not inputs. Under the current fee-for-service model, there is an incentive for quantity of effort – that’s where the money is made. By moving to a system that pays for service value, not volume, and emphasizes wellness, prevention, patient outreach and better outcomes, we can cut costs and move the focus from treating problems to preventing disease.
For the state’s direct health care costs, we can do a lot to make Medicaid less costly and more successful. The Urban Institute estimates that Washington would see an additional 325,000 people enroll under the Medicaid expansion called for in the new law. But we can’t simply dump these Washingtonians into the current unsustainable Medicaid system, where they will face barriers to access and substandard care options.
Legislators and the next governor must take a comprehensive look at the short and long-term budget impacts of any Medicaid expansion as they shape the safety net for our most vulnerable citizens. The Supreme Court’s decision on Medicaid provides new state leverage for a dialogue with the federal government about Medicaid’s cost trajectory and our pressing need for regulatory flexibility, meaningful consumer engagement and delivery-system reform.
With the Supreme Court’s decision announced, we must now shift our focus to finding Washington state-specific solutions for our health care spending crisis. This will require innovative thinking that spans old, partisan divides. I am committed to moving us forward as your next governor. Simply put, we can and must do better than Washington D.C., and the time to start is now.