When Eliot Spitzer provided a one-word “yes” answer to the question of whether he would bring about universal health care, I can only hope that he meant he would do so someday as President, not as Governor. After all, providing health care for every severely ill person in the United States without health insurance would be a big burden on the New York State tax dollar, perhaps leaving no money for anything else. And as a result of a Supreme Court decision in the wake of welfare reform, which held that any benefit offered to state residents must also be offered to everyone else, that is exactly what would happen. Anecdotal evidence suggests this happens, to an extent, already. Still, while I believe a universal health care financing system must, and should, be implemented on the federal level, there are some things a New York State Governor could do to bring it about.
First, the Governor could identify and publicize the number and cost of those arriving here from other states for Medicaid-funded care. These include seniors, who prefer to live in lower tax states when they have resources but often return in later old age when their money is gone and they have custodial care needs, the mentally ill, poor people with family in the area who have a condition requiring an expensive procedure, like surgery, and those without family members here who just know the care is better. The Governor should object to New York taxpayers having to fund care that less generous states fail to provide. And if the Governor of Florida objects that many former New Yorkers are in Florida nursing homes, in part at Florida’s expense, New York should agree. That is another example of the reason a national system is required. Pennsylvania and Iowa, with high median ages, also suffer when seniors with needs live in their state while the taxpaying young live elsewhere. There is scope for an alliance, and pressure of federal representatives.
Alliances can be formed, and pressure applied, on the federal Medicaid matching formula as well. This formula, which is based on per capita (not median household) income and not poverty, has long disadvantaged states like New York and California that have a few rich people pulling up per capita income but are not wealthy otherwise. But it is also working to the disadvantage of the declining Midwest. Michigan, for example, is facing a downward fiscal spiral, and yet the federal government’s Medicaid formula is transferring money from Michigan, where the auto industry is shrinking, to states like Tennessee and Alabama, where it is growing. No one is going to listen to New York on Medicaid, since its spending is so high is captures a huge share of federal Medicaid spending despite the low federal share. But Congress might listen to Michigan, Ohio, and Indiana if alliances can be built there.
The recent split among unions into two camps also provides an opportunity for alliances. While paying lip service to universal health care, the traditional unions, led by the public employee unions, already have employer-provided health insurance for their members. They have been unwilling to push for health insurance for other workers, since that would mean either higher taxes (if funded by government) or higher prices (if funded by business) for themselves. If there is a guiding principle of those unions, with their multi-tier contracts and rich pensions, it’s “I’ve got mine jack.” But now those who don’t have theirs are in a separate coalition, whose leader seems to understand that the tie between health insurance and employment isn’t good for business, labor, or – given that the current system inflates health care costs including public health care costs – taxpayers. Therefore, the Unite to Win coalition is another group that could be worked with to push Congress to do something for those without.
The key, however, is to convince large segments of the business community to support universal health care at the federal level. More and more business leaders are reaching the conclusions that I reached here. More and more can, with a little convincing. To push the issue, perhaps New York State could try to reach out to young entrepreneurs who, with little initial income and little wealth (other than their businesses which, given that most fail, could be valued at zero) could be eligible for Family Health Plus. In particular, those willing to live very cheap in low-cost Upstate may be willing and able to get buy on a FHP-level income as they build their company. If New York were able to attract and support more entrepreneurs by doing so, those in other states might decide a national system might make sense for them too. Of course, those in their 50s, with savings, business contracts and experience are actually better able to start new businesses, but the threat of financial ruin if they become ill while doing so keeps them hanging on to corporate jobs. This economic loss should be pointed out to non-corporate business people – and those worried about the next round of corporate layoffs as the economy evolves — all the time.
The most important thing the next Governor could do to bring about a national health care financing system, however, is to reform, and cut the cost of, New York State’s Medicaid program. That program is everyone’s worst nightmare of public involvement in the health care industry, or for that matter any industry. It has been completely captured by producer interests, and used to subsidize the inefficient, overpaid, obsolete, those with a greater sense of entitlement, and the politically connected to the detriment of basic care for the needy, and at an extravagant cost. It raises the question, particularly given the escalating cost of President Bush’s trillion dollar give-way to the already privileged but politically significant seniors –whether any and all public involvement in health care is likely to be worse than nothing based on equity AND efficiency. If the next Governor could turn New York’s Medicaid program into a way to provide health care rather than a way to reward political supporters, it might change a few minds about what the government is able to do. If that Governor were a Democrat forced to make hard demands of his nominal supporters (even if those supporters have proven willing to back anyone in exchange for a better deal), so much the better.
Thus one of my main state concerns — preventing Medicaid, debt service and pensions from sucking up all the money and leading to collapsing public services with high taxes in New York — matches one of my main federal concerns — a more equitable and less economically damaging health care finance system nationwide. An unenlightened view would call one "conservative" and the other "liberal," but in fact they both involve acting in favor of the less well off, the less well organized, and those with the fewest choices. I’m not sure what that is called today, but it is what I am in favor of every time.