In 2008 Arizona, a hotbed of radical anti-government sentiment, the electorate almost passed Proposition 101, "The Freedom of Choice in Health Care Act," that would have put the following into the Arizona constitution:
Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan.The vote could hardly have been closer - 920,341 (49.8%) for and 928,452 (50.2%) against. A tweaked version of Proposition 101 will be on the 2010 ballot and may well win this time.
The brain trust behind the rebellion is the American Legislative Exchange Council (ALEC), a 30+ year old organization of conservative state legislators and policy analysts. ALEC's model legislative proposal is only available to members, but the gist of the proposal is can be seen here:
When consumers control the dollars, they make the decisions. On the other hand, a single-payer health system—which forces patients to enroll in a one-size-fits-all plan with rich benefits and weak cost-sharing—will cause spending to skyrocket and policymakers to ration care as a cost-containment measure...Under a socialized medicine scheme, many patients will suffer, and some will die on a waiting list...ALEC's Freedom of Choice in Health Care Act ensures a person's right to pay directly for medical care.ALEC pushes all of the conservative buttons - "one-size-fits-all," "ration care" and "socialized medicine."
ALEC and the legislators in the twelve mandate-fighting states appear to favor the "consumer-driven" approach to health insurance, in which individuals are asked to do their own rationing by having to spend their own money on health services. I don't know how ALEC proposes to achieve universal coverage without a mandate. The alternative funding mechanism is to tax the better off to pay for the worse off, not a popular conservative approach.
When I first joined the practice at Harvard Community Health Plan, a non profit HMO, in 1975, "community rating" applied, and all employers were charged the same per-worker premium. Over time the payment system shifted to "experience rating," in which employers were charged in accord with the actual cost of providing care for their employees. This meant that employers were penalized for having older workers who were likely to cost more, and for making it possible for workers with chronic illnesses to hold jobs. Now conservative groups like ALEC want to disaggregate the community down to the level of individuals having the "right" to pay for their own care.
Even if a robust federal health law is passed states will continue to be crucial laboratories for reform initiatives. I'm at the opposite end of the political spectrum from ALEC and favor communitarian approaches to managing the health system. But I'd be happy to see an ethically guided state experiment that (a) achieved universal coverage, (b) tracked its results and allowed independent researchers to assess the state's performance, while (c) putting conservative principles into practice. My guess is that the rebellious legislators are better at shouting "fire" (or rather, "socialized medicine") than solving problems on the ground, but rather than trade sound bites it would be better to see if they can make their ideas work in a clinically sound and socially responsible manner.
Conservative critics of health reform emanate sound bites brilliantly. It's time to see if they can walk their talk!
(An op-ed supporting Arizona Proposition 101 by George Will is here. The Resolution that will be on the Arizona ballot in 2010 is here.)