The US constitution sets up a system of checks and balances for the three branches of government, the Executive (White House and Cabinet), the Legislative (the “Congress- House and Senate) and the Judicial (Supreme Court). The ability of the Legislative Branch to regulate our lives- economically and socially- involve four enunciated powers within that document.
The first says Congress can “lay and collect taxes”, obviously a clear indication that we can be taxed. The second power affords Congress the right to regulate our economic activity under the “commerce” clause. Since Congress has the requirement to “provide for the common Defence (sic) and general Welfare of the United States”, we understand it can regulate spending. Finally, given the 14th (equal protection, due process) and 15th (guarantee of the right to vote, irrespective of one’s race) Amendments, Congress has enforcement powers. These powers ebb and wane, as the other two branches exert their influences.
Until Rehnquist was appointed Chief Justice, the Supreme Court (SCOTUS) posited that the political process was the primary process to limit the powers of government. But, Rehnquist limited statutes passed by Congress that narrowed the commerce and enforcement definitions, when SCOTUS refused to allow state workers to sue their employers (the states), when deciding the validity of the Violence Against Women Act and the Americans with Disabilities Act, as well as the Family and Medical Leave Act.
Now, what people may have missed by the SCOTUS ruling on PPACA (Patient Protection and Affordable Care Act, aka “Obamacare”), the Roberts Court has further limited the power of Congress. Spending power, as in the inability to deny Medicaid funds to states if they don’t comply with the expansion stipulated by PPACA , has been constricted. This may, in turn, render it more difficult in the future for Congress to demand compliance with new objectives it decides upon; since according to this decision, Congress can only stipulate priorities via its taxing power. Only time will tell.
In the meantime, there are two key issues to be resolved. The first is the looming deadline for states to institute “Health Insurance Exchanges” (HIE), that will afford their citizens information about the choices for insurance available to them. If they fail to meet the criteria required, a federal solution will be applied for that state. The other issue is expanded Medicaid coverage for the working poor (which expansion will be funded for the first few years in full by the Federal government, dropping to 90% after a few more years, and dropping further towards the end of the ten year transition period of PPACA). (One should note that those folks whose income ranges between 133% and 400% of the poverty line will receive tax credits to offset the cost of health insurance.)
One thing for certain now is that about 12 (of 26 Republican) states are going to be recalcitrant in developing that Medicaid program for the working poor. (Some others will also fail to develop HIE’s.) The poor are already covered by Medicaid; the working poor are folks that are below 133% of the poverty line. This group of folks are supposed to be covered by the expanded Medicaid, and the the Robert Courts limited the ability of Congress to withhold existing Medicaid funds, should a state decide not to comply with the expansion.
However, one can expect the hospital industry to lean on these states who “opt out: of the expanded Medicaid coverage to insure that uncompensated care (where the uninsured poor don’t pay their bills) won’t drain their hospital’s coffers. That fight will be between the Republican politicians (in those states) and their big donors, the hospital industry. We know who will win that one.
As I struggle to understand all the “obamacare” you are the voice of sanity in the wilderness of childish name calling. Thank you for that. I am also sad my state is one of the ones in yellow, but not surprised. I think it was Schopenhauer that stated that truth passes through three stages, first it is mocked, second it is violently opposed, and then finally accepted as being self evident. I’m paraphrasing, but think I will find a quote picture and write about it soon…Just once I’d like to skip one and two to get to the good stuff. America is changing, and it is bringing about a lot of turmoil. This health care debate is just another example. Frankly, I see everyone being able to be treated medically as a wonderful thing with all politics and business aside. I’ve seen too many people NOT be able to get health care and die as a result. I told a lady the other day and will say it again now, “I’d rather pay for 100 so called lazy people to get treatment than I would one funeral.” Sadly, I’ve already paid for one funeral that could have been avoided had he had access to proper medical treatment. And he was far from lazy, he was a hard working man. I’d also say frankly, that if we took care of each other better we wouldn’t need government intervention. People don’t seem to understand that it is because of the decline in care among individuals we seem to need these laws. Don’t like the need for the law, do something other than call people stupid, idiots, and lazy and actually take care of each other. Ok, sorry, I’m rambling. Great post!
Lisa Brandel recently posted..The Painted Lady by Lisa Brandel
Yes, Lisa, Obamacare is a bit long. There was a choice- one could have made health insurance reform very simple- by eliminating all private insurance and running the program like Medicare. Then, there would not have to be all the provisions that would afford compatibility with the plethora of plans that are available, to insure that existing insurance would not be terminated by employers, that the poor would be covered, that private insurance would not suffer greatly with the elimination of the pre-existing conditions, etc. Just listing these conditions makes it clear why the program has to be somewhat convoluted. But, that’s what maintaining private enterprise is about- NOT throwing out what business is already doing to start something new (although I personally believe the current system is not worth saving…)
And, let’s be honest. There will be coverages of conditions that are denied. What makes government panels of experts LESS likely to make the correct choice than that of an insurer trying to maximize its revenue? Really! Because, we need to insure the best coverage for the most prevalent conditions for the most citizens- period!
Roy
Roy, because of a condition I have, I have been classified as being in a high risk health pool in Texas. I pay $600 a month for my own health insurance. I also pay plenty for services. I don’t see how people can afford this if they have to cover their families and pay for food at the same time. I have to work to pay for this and I know if I get cancer or something, I am going to be out of luck. There is something wrong with the system. I wish they had done what you suggested and just turned medical care into a governmental entity. Why have wars on drugs and terrorists, but not a war on illness? PS The Constitution was set up with a second set of checks and balances between the federal government and the states, where those in need were expected to be helped by their neighbors like Lisa suggested.
Ann Mullen recently posted..Senior Care: Watch for Medication Mistakes
I agree with you, Ann, that the way our insurance is handled leaves a great deal to be desired. One of the fun” things is how they classify small businesses- they assume that each small business can’t be rated (even if it can, they won’t) and then just apply an across the board 8% increase or more every single year for the past five years. (This is true for the nine clients for which I handle accounts payable. Interestingly, none of them have high risk patients and for at least two of them [since we pay the deductibles for the employees] their total visits costs almost match ONE month’s bill (for ALL the employees.)
Your state is a prime example why the insurance did not become a single payer. You have a governor, a lieutenant governor, and representatives that would scream bloody murder, had that happened.
And, there are NO checks and balances between the states and the feds per se- it’s just that certain rights were arrogated to the central government and the other rights resided with the states. And, some other rights were taken when states took funding for various activities from the feds.
Roy
I enjoyed reading your take on what happened with the recent ruling on PPACA. It is always nice to get a non-political analysis. However I am actually happy that the ability of the Federal Government to force states to add to their medicaid rolls was restricted. The fact is I live in a state that was listed 4th in the most likely to go bankrupt. With states already struggling with trying to make up shortfalls, I don’t see how they can increase the cost of a program that at best may provide ‘insurance’ but does not really guarantee ‘access’ or ‘quality’ of care. Many Doctor Offices here have signs that they cannot accept medicaid or medicare patients. Why? Because the reimbursement rates are so low, they can’t do it and remain in business. I believe that ultimately this situation will not be ‘fixed’ until the patient and the providers are put back in charge with the government and insurance companies providing a financial safety net only. If you really dig into PPACA, there is really nothing that ‘guarantees’ access–only that you can purchase an insurance policy or participate in a government program that in the end will not be worth the paper it’s written on. It doesn’t guarantee quality, especially when there is nothing to encourage growth in the provider sector to support the influx of new patients. I also have a friends who have not been able to get ‘insurance’ due to various medical conditions, some life threatening. However, what they have found is by working with the providers, they are receiving care without PPACA. Insurance would make it easier for them financially, but they are not denied care. The American People are the most generous on the planet. Look at how much can be raised for national disasters both here and abroad with the click of a mouse. Instead of relying on the government to provide, perhaps we should try having those who can afford it, provide a donation to a non-profit whose sole function is to cover the financial side of the equation and then leave the actual care decisions between the doctor and patient. Who knows, maybe then the money might actually get to the patient instead of being used by the government in ways it was not intended (social security anyone?).
OK, Robin, let’s address some of these issues. (I hope!)
Many states are, indeed, in financial trouble. Their woes have nothing to do with Medicaid, but with the recession, their inability (or lack of desire) to increase taxes to cover services (that they don’t want to reduce), or similar circumstances. However, for at least the next few years, the increased costs for expanded Medicare (up to 133% of the poverty line) are covered by the Federal Government. There is no cost for this expanded citizen benefit to the states. It also will reduce uncompensated care at the hospitals- which funding is often made up by the states- so this saves them money. If the hospital is for profit, there will be increased profits. There will be increased revenue for health care workers- which will increase taxes to the state. And, providing better care (more preventive and less emergency) should lower health care costs, overall.
And, many doctors refuse to process Medicaid payments because of the paperwork involved. However, there are other physicians to choose- and there will be more family physicians entering the market soon (as well as welness clinics and nurse practitioners, which will provide some of this new, added care (for new enrollees) at rates below these other professionals, which will also save money.
The problem now is that we have guaranteed access to hospitals- which is why so many NON-emergency cases end up at the hospital. Why so many of them never pay their bills (some because they can’t). Given the new health care insurance, they can be directed to the less expensive clinics, get their treatment, and cost less money.
I also beg to differ with you with the ability of a non-profit to respond to emergency situations, based solely on donations. The Red Cross, for example, makes money from its blood services (and, as a medical device supplier, which is what that is called, has the highest number of consent decrees [think HIV-infected blood, refusal to do additional testing]) that provides many of these funds. Plus other grants.