Can State Governments Set Up Universal Health Care on Their Own?

By Ezra Klein, Washington Monthly. Posted August 8, 2007.

It is one of the happy incidents of the federal system," Supreme Court Justice Louis Brandeis once mused, "that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country." Well, quite. These days we practically expect the states to try their hand at fixing tricky national problems before the federal government steps in. So to many observers, when several states recently turned their attention to providing health care for the uninsured -- one of the thorniest domestic problems of all -- it looked like cause for considerable optimism.

For a start, both Massachusetts (which passed a near-universal plan last year) and California (which is seriously debating one) are trying something relatively new: individual mandates that require every person in the state to have health insurance. The fact that Democratic legislatures have pushed Republican governors -- one a presidential candidate (Mitt Romney), the other a celebrity (Arnold Schwarzenegger) -- to back the notion of universal care has given this perennial liberal dream a bipartisan cachet. It has also helped revive the national conversation around universal health care by moving the discussion from airy, moral exhortations to practical examples of possible paths forward. In fact, the leading Democratic presidential candidates have all committed themselves to universal health reform, some with plans that seem more than a little influenced by those statewide R&D centers. The laboratories of democracy appear to be in fine working order.

So far, so good. But we know that the politics of health care is treacherous. In the last half century, two presidents (Truman and Clinton) mounted serious efforts to provide health care to all the uninsured and failed, while another (FDR) scotched his ambitions when he appraised the obstacles. There's no reason to think that things will be any easier this time around. Consider this: congressional Democrats, despite their new majority, were recently unable to pass even minor tweaks to the Medicare prescription drug benefit. If a Democrat wins the presidency in 2008, he or she will face a daunting array of moneyed interests aiming to kill any universal health care program they attempt to pass.

Faced with such long odds, a conventional wisdom will soon develop that it would be better for Washington to defer efforts to pass universal health care, perhaps indefinitely, and instead just leave the problem to the states to figure out. Indeed, such arguments are already being voiced by ideological opponents of expanded federal power. "Let's just try many different approaches in many different states and see what happens," the Heritage Foundation's Stuart Butler told me. "The more complex an issue is, the less possible it is to actually know the best system in advance -- therefore a system of trial and error in which all these pieces work together is the best way to push forward."

The idea of giving universal health care a little more time in the laboratories of democracy may sound tempting to certain cautious, bipartisanship-loving Beltway observers. But letting states continue to take the lead would be disastrous, for one very simple reason: providing health care for all citizens is one of those tasks, like national defense, that the states are simply unequipped to manage on their own. The history of state health reform initiatives (and there's quite a history) is a tale of false hopes and great disappointments. The deck is stacked from the start, and the house -- in this case the insurers, the providers, and other agents of the status quo -- always wins. The new raft of reforms may prove different, but they probably won't. Universal care advocates must be realistic about that, and think hard about how to convert the energy in the states into a national solution before the current crop of novel experiments fail -- because fail they almost certainly will.

The current appetite for universal health care in state capitals may seem thrilling and unprecedented to some, but to those who follow the issue it carries an unsettling charge of déjà vu. Over the years, states have tried programs of many different ideological and economic persuasions. All of them failed, and not because the programs were insufficiently inventive, but because states are structurally incapable of sustaining them.

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Ezra Klein is a junior at UCLA. He does have a blog; it’s at http://ezraklein.typepad.com. He does not work for the school newspaper. Which leaves him time to respond to your e-mails: ezrak@ucla.edu. Who do you want to see profiled in Get a Job? Drop him an e-mail and let him know.

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