Phony federalism: On health care, GOP leaves dirty work to states

Republican congressional leaders have offered health insurance solutions based on phony federalism.

In Maine, Gov. LePage and Sen. Collins provide sharply different views about this way of dealing with health insurance.

The GOP congressional ploy would shift some tough decision to the states. That might look like an effort to enhance the role of states, but it just sheds congressional responsibility, when compromise is impossible. Or it allows special sweeteners for select states.

Members of Congress can say, “I did not vote for that measure, but left it to the states to decide.” Each member could then claim to have supported or opposed the new law, as it suited them.

This supposedly appealing boost to federalism has been used by the Republicans on several issues. Now, with complete control of Congress, they should be able to pass any bill that can avoid the Senate filibuster.

But the health care debate has cost the GOP critically needed votes from both the most conservative and moderate members. The state option is meant as a solution for both sides.

With only a handful of states under solid Democratic control, Republicans leaders might conclude they can repeal the Affordable Care Act and pursue other conservative policies through state action.

The Supreme Court ruled that states cannot be required to accept Medicaid expansion to cover more people, but they could do so voluntarily. Somewhat surprisingly, 31 states and D.C. opted in, while 19 did not take the option.

Among the 30 states that voted for Donald Trump in 2016, 13 have opted in and another seems to be on the way. Thanks to federal government financial support, those states have placed expanding of the number of people with health insurance ahead of partisan politics.

Only two states that voted for Hillary Clinton have refused the option. One is Virginia, where the state government is divided between the two parties.

Maine is the other, having failed to opt to expand Medicaid coverage, as Gov. LePage’s allegiance to GOP conservatism with his party’s legislative support, overrode extending health care access in the state. Voters will vote in November whether to override the governor by adopting a citizen initiative to accept expanded coverage.

Based on the Medicaid experience thus far, the GOP leave-it-to-states approach may not work well. Only if appearances, not substance, are what matter to members of Congress, would this ploy be useful.

One result of the Republican scheme is to enhance the role of many governors in the federal legislative process. In the past, senators and House members infrequently consulted governors.

Now, in states that voted Republican in 2016 but opted for expanded Medicaid, governors are making clear they want no ACA retreat, as has been part of every GOP health reform alternative. Governors won’t strip people of coverage they only recently obtained.

That leaves congressional Republicans caught between the demands of national party policy opposing Obamacare, and the demands of their own states as voiced by their governors. Being opposed by Trump when running for reelection next year may seem preferable to being opposed by the governor.

Though LePage has blocked expansion, Sen. Collins courageously opposes slashing Medicaid nationally and has never supported outright ACA repeal.

The split between GOP governors and Republican congressional leaders may influence the 2020 presidential election, assuming Trump is not assured of the nomination. Because most senators are under pressure to stick with the party line on health care and other issues, their ability to influence the debate is limited.

A hopeful like Florida’s Marco Rubio has little room for maneuver. Like many other congressional Republicans, he must vote for reform proposals that are more like repeal to keep faith with electoral promises made by his party.

By contrast, Ohio’s GOP Gov. John Kasich, whose state opted for expanded Medicaid, is free to come up with his own ACA reform proposal. He has offered his ideas as the basis for negotiations on a compromise, favored by many voters. He shows his independence, and his visibility is enhanced.

Two key points emerge from this attempt to use federalism for purely partisan reasons.

First, Congress cannot effectively dodge its own responsibility to adopt legislation of national scope. States cannot be relied upon to be partners in party policies when they run counter to state interests.

Second, states can experiment with policies before they are adopted nationally. But that means if Washington supports any state option, it should support all options from single payer to subsidized private insurance, not only those choices that are barely disguised repeal.