Health Care/Joan Retsinas

States as Countinghouses

Chief Justice Louis Brandeis labeled states “laboratories of democracy,” free to experiment with new programs, away from the federal government’s edicts. Today singer Oliver Anthony, crooning about “Rich Men North of Richmond,” echoes that enthusiasm for letting states rule, for keeping Washington out of the expensive decisions.

Let’s relegate Brandeis’ vision to a historic footnote.

Today states have emerged not as laboratories of democracy, but as countinghouses where Scrooge, pre-redemption, would feel at home. Ironically, the “rich men north of Richmond” have tried to help those workers south of Richmond struggling with poverty, addiction, illness, racism, unemployment. … The “men south of Richmond” have not.

Look at health insurance. Many states, looking at health insurance, decided “no.” Or if they decided “yes,” they did so grudgingly. States are in charge of Medicaid, the federal/state program that insures poor women and children. The federal government has paid part of the tab; the states, the rest; and the states set the criteria, the coverage decisions (with thresholds set by Uncle Sam). The Affordable Care Act offered states an incentive to expand Medicaid, with Uncle Sam initially paying most of the tab. The hope was that expanded Medicaid, coupled with the Affordable Care Act’s umbrella, would cover most Americans, giving them access to our wondrous healthcare facilities, protecting them from impossible bills, assuring them medications and outpatient care. A giant step toward a healthier populace.

States debated. Many states seized the chance to cover more residents. But many states demurred. Today Wyoming, Kansas,Texas, Mississippi, Tennessee, Alabama, Georgia, Florida and South Carolina say “no.” (Missouri, Oklahoma, and South Dakota eventually changed their “no” to “yes.” North Carolina has not implemented their “yes.”) Even with the carrot of federal money, those states voted “no.” They did not dip into state coffers to cover those uninsured residents; they simply raised the banner of states’ prerogatives (eerily akin to states’ rights), coupled with “tax burden,” to leave swatches of their populations without insurance and, consequently, without consistent healthcare.

Today the grudging decisions continue in the halls of statehouses, particularly those south of Richmond. A few states — notably Arkansas — want to tether Medicaid to working, demanding that poor folks work if they expect to see a physician. Federal courts have blocked those initiatives.

States’ current big decision: do we pare the Medicaid rolls, dropping those people they continued to cover during the pandemic (required under federal law). Now that the country has come out of the pandemic (thanks in large measure to vaccinations, developed not by states but by scientists, and distributed not by states, but by federal initiatives), states can re-formulate their eligibility requirements. People must sign up, fill out the forms, demonstrate anew their eligibility — all reasonable, all part of states taking control. The upshot: 25 states have purged at least 1.5 million people. Arkansas has dropped more than 140,000 people; Florida, 250,000; Indiana, 54,000. The key culprit: “procedural reasons.” People didn’t receive the forms, didn’t fill them out correctly, the processors didn’t process the forms in time … It is easy to trap people in a bureaucratic net.

As to the generosity of Medicaid, Wallethub analyzed spending by state. The five states spending the most per low-income resident were Massachusetts, Alaska, Vermont, New York, Rhode Island. The bottom of the rung were Utah, Florida, Oklahoma, Alabama, Georgia. The states claiming the bottom rung can boast of fiscal frugality; I doubt their poor residents are as pleased.

We let states rule on abortion. That upshot: a pastiche of rules and regulations not just for the procedure but for the distribution of mifepristone, a drug allowed by the FDA. A woman with an ectopic pregnancy is better served if she lives in Minnesota than in Alabama. Not surprisingly, we have “abortion” travel as women seek the procedure hundreds of miles from their homes.

Finally, school meals are expensive. Children eat a lot. Their moms, channeling June Cleaver, should be serving them wholesome breakfasts, packing them nutritious lunches. If the children eat “school lunch,” their parents should pay, if their incomes are above guidelines. There is no such thing as a free lunch. The arguments go on and on, in states keen to showcase fiscal frugality. Kudos to the eight states that decided “enough.” Let’s simply feed the children — no eligibility guidelines, no special cards to demarcate “free” from “reduced” lunches: Minnesota, New Mexico, Colorado, Vermont, Michigan, and Massachusetts, California, and Maine. Other states may follow suit.

Associated Press: “Schoolkids In 8 States Can Now Eat Free School Meals, Advocates Urge Congress For Nationwide Policy.”

The enthusiasm for “regular” working folks hamstrung by Uncle Sam is mythic, as is the zeal to let States Houses, from Little Rock to Tallahassee, rule. The argument resonates: It would be cheaper to put states in charge. But the mythic is just that: mythic. The countinghouse states have pared their budgets on the backs of those regular working folks, north and south of Richmond.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, October 1, 2023

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