The Coming Crisis in Healthcare and its Possible Solutions
An Open Letter to Colleagues at the New School and Beyond
It is fair to say that the New School community, and especially many of its students, are still in a state of shock after the results of the presidential elections. Some people hoped for a reversal in the electoral college, or perhaps an early impeachment. Neither was going to happen. We must get beyond shock and imagine solutions to a very real set of problems that will challenge many areas of life of American citizens, including, possibly, the survival of liberal democratic institutions. With that in mind, we thus propose that part of the work of the New School could be re-oriented to generating and proposing policy alternatives, rather than remaining a diffuse center of abstract resistance. We already embody the latter, but without sufficient influence on what is about to happen. We should become the former, and try to influence outcomes through institutions that are fortunately still alive and well.
The subjects we propose to consider are in the area of health policy, and the instruments are in the domain of federalism, to avoid misunderstanding, “progressive federalism,” meaning normatively attractive forms of experimentation on the level of the states. While we strongly believe that similar initiatives are needed in the areas of immigration, women’s and parents’ rights, civil rights, environmental policy, labor rights and so on, we think that it is important for these several areas of concern under a Trump administration to be studied and considered one by one, and in sufficient detail so that viable initiatives can emerge from our work. Health care is our proposed initial area of focus, not only because it is a natural topic for the Schwartz Center for Economic Policy Analysis (SCEPA), but also because it is highly likely that in January 2017, the US Congress will repeal the two core dimensions of the Affordable Care Act (ACA), the subsidies and the mandates, and very possibly also the very important Medicaid expansion. This will undoubtedly cause a veritable crisis, not only for the millions who will not be able to afford insurance, but for the health care industry as well (loss of demand; tensions between remaining parts of the ACA and the elimination of these key dimensions). This will happen even if implementation of the repeal will be delayed for a year or two or three. Alternatives will be needed very quickly, especially as the Republican plans of “replacement” are meaningless and are not likely to get sufficient Senate support to overcome the filibuster.
This is where federalism comes in. Progressives in the United States tend to assume for historical reasons that (“states rights”) federalism is always the enemy of progress. This is wrong historically, since contrary to the epoch of the late New Deal culminating in the civil rights movement and the Warren Court, in the earlier Lochner period, it was a national institution, the Supreme Court, that blocked reform in the “laboratory” of many of the states. Given the current division between blue and red America, it should be possible to re-activate that laboratory on a state by state basis, or several states acting together regionally, starting with our own New York State.
So this is what we propose. As a first step, we would like to organize a small or mid size study and research group containing economists, sociologists, lawyers and medical anthropologists. This group would, start, possibly during the winter break with some collective reading (starting perhaps with Jacobs and Skocpol Health Care Reform and American Politics and if possible a good text on international versions of health insurance) and go on to consider in weekly or biweekly seminar sessions problems such as:
- The internationally available systems of health insurance (single payer, mandate-insurance using either profits or non profits, and two tier models, as they may be relevant to large states like ours, with 20 million people, and great wealth (50th in world comparison, 10th with respect to Europe!), as well as to a region like ours.
- The politics and economics of a probable (but not certain!) attempt to repeal parts of the Affordable Care Act by Congress, with the President’s approval (itself uncertain!).
- The ACA, that will most likely survive the first set of attacks that will affect only parts with budgetary implications (the rest is open the filibuster). Consider the likely effects of such a new deformed mixed system on the insured and the insurance companies.
- Openings in the Act for independent state action (e.g. single payer, public option, state level mandates, regional partnership, use of the Federal Office of Personal Management in state exchanges etc.).
- The history of Romney care in Massachusetts, that would be a possible model, its successes, failures and plans for improvement before the ACA.
- The single payer scheme in Vermont, how it was adopted, and why it failed, and what alternatives have been considered after its failure.
- Proposals of single payer insurance and, or public options in New York, California, Colorado and elsewhere, how these would work, and the chances of their success (and the political as well as budgetary reasons why so far they have been failing).
- The politics of NY and neighboring states, trying to understand the pros and cons of establishing any of these options or other alternatives, given the specific politics of NY state linked to the likely remaining parts of the ACA and Medicaid as well as Medicare.
- The question of possible constitutional limits to “progressive federalism,” as interpreted by the Supreme Court historically, and as a future Court with one Trump appointed member may interpret them in line of precedents both with respect to the ACA, and in other domains of the law (e.g. local attempts at gun control; DC parental leave; state level environmental protections).
If we come to some agreement concerning a project that we would advocate, as a second step, we could go further and try to construct the outlines of some (one or two) alternative proposals that would deal with both the crisis as it will soon emerge, and the political options available.
Concurrently with these two steps, perhaps beginning in late February or early March, we could begin to make our discussions and eventually, if successful, our projects more public. Such sessions would be the most difficult to organize and would require some funding, but potentially they may be the most productive. We should move to some public events as soon as possible. The move would involve setting up:
- Visits, including public lectures, by a. health commissioners from neighboring states (Dr. Howard Zucker in New York), health care experts (scholars and journalists, medical administrators and insurance company experts) from NY and nearby state, lawyers familiar with this dimension of federalism,. health care experts of large labor unions in our area, and possibly the governor of the State, and Democratic leaders of the two chambers (and of neighboring states possibly?), and certainly political leaders of efforts to establish universal systems in NY, Vermont and elsewhere ( Richard Gottfried, chair of NY Assembly Health Committee )
- Some of these visits could be part of one or two larger conferences we could organize at the SCEPA that would reflect the organization of the topic as 1-9. Here it would be very desirable to include speakers from other states, in the East and potentially California, Oregon, Colorado, Illinois and even red states too where we have access.
During these public lectures and conferences our aim would be of course to learn, but also to test our outline proposals with our guests. The ultimate aim is not only to refine one or two proposals we would make, but find politicians and administrators willing to sponsor some variant in the legislative process in New York, and potentially elsewhere.
The first step is to organize a New School group. We are writing to you hoping that you will join us, and we welcome your suggestions about possible ways of improving the project.
Sincerely Yours, in Solidarity,
Andrew and Clara