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Win or Lose, The Affordable Care Act Has Federalized Health Care Forever (Forbes.com) July 13, 2017

Posted by daviddavenport in Op/Eds.

Writing about President Lyndon Johnson’s “Great Society” of the 1960s, which triggered an avalanche of new federal programs, political scientist James Q. Wilson rightly said that one thing LBJ accomplished was lowering the “legitimacy barrier” to federal action.  Previously, Wilson pointed out, there were serious debates over whether the federal government had the power to tackle domestic policy challenges such as poverty or welfare or Medicare.  But once the first laws in these fields were passed, that debate was over and everything that followed came to be seen as an extension or a continuation of some legitimate federal program.

If nothing else, this is what President Obama’s Affordable Care Act accomplished: it forever changed the debate by making health care policy a legitimate matter of federal concern.  Today Republicans and Democrats no longer argue whether federal health care regulation and design are legitimate; instead they argue the details of federal policy.  The questions are not whether, but how much.  The debates are about how many people have coverage, whether preexisting conditions must be covered by law, the proper scope of coverage, and so on.

This is the primary problem conservatives now confront in trying to cut Obamacare down to size.  They would like to repeal it, and try to return things to the pre-Obamacare days, but most of them understand that politically they can’t realistically turn back the clock.  They cannot repeal if they do not also replace.  And when they replace, they would like to make greater use of private insurance, spend less on Medicaid, and eliminate mandates, but Obamacare made the debate about how many millions of people are left uncovered by health insurance, so that becomes fatal to many of the Republicans’ plans.

Even though Obamacare did not literally federalize the delivery of health care, it did federalize it in the crucial sense that the federal government is now in charge of making the important policy decisions about it.  It is no longer the states or the doctors or the private health insurers interacting with patients and consumers that are deciding the scope of required health care.  It is Mitch McConnell and Ted Cruz and maybe Chuck Schumer.  This is boiling the frog federalizing:  first we lower the legitimacy barrier to federal action, then we put the feds in charge of the key policy decisions, and,  ultimately, we are likely to end up with federal delivery of health care.  This was all accomplished in a stunningly brief period of time, and all triggered by a party-line vote on Obamacare.

In the same time frame, though accomplished more slowly, was the federalizing of K-12 education.  First, through President George W. Bush’s “No Child Left Behind” law, followed by President Obama’s “Race to the Top” program, the federal government began to take over what had traditionally been understood as the classic state and local matter:  K-12 education.  But amazingly, there was pushback from parents and teachers over the Common Core curriculum, teaching to the test and other problems.  Finally, Congress realized it had to pull back and the “Every Student Succeeds Act” essentially admits defeat on some of these federal programs and begins returning authority to the states.

Are there useful lessons in reducing federal influence in education that might help trim the sails on Obamacare?  I fear not.  By the time Obamacare fully plays out, and all its problems are discovered, a federal system of health care regulation will be so ingrained that it will be possible only to amend it, not to pull it back.  It will take tremendous courage on the part of Republicans to seize the only moment they now have—and even this is likely too late—to turn back the federalizing of health care.  Far more likely is that the federalizing will ultimately take over the delivery of health care itself through a single payer (government) system.  Few want that, but once the federalizing starts, it becomes almost impossible to stop.


To view the column at Forbes.com:


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