6 ms·

As a non US Citizen, I have a question: If Obamacare is repelled at the Federal level, could a state just implement its local ACA? what prevents California for

by vmarsy 10y ago

As a non US Citizen, I have a question: If Obamacare is repelled at the Federal level, could a state just implement its local ACA? what prevents California for instance of giving health coverage for its residents? California is a good example since it "the world's sixth-largest economy" (If California was a country) I'm sure healthcare companies wouldn't want to cut themselves out of this market? This would give California and SV an even bigger advantage regarding what is described in Sam's post.

acchow 10y ago
> This would give California and SV an even bigger advantage regarding what is described in Sam's post. Btw, San Francisco has essentially had universal health care since 2007 (via Healthy San Francisco), though it doesn't cover non-residents on I-94. It would be interesting to see if citizens and permanent residents represented a high proportion of founders in SF than, say, Silicon Valley.
- elastic_church 10y ago
  > The program is open to city residents, ages 18 and up, whose incomes and net worth are low but who do not qualify for other public coverage, and who have had no insurance for at least 90 days. Ah the classic "if you are middle class F U" program
Judson 10y ago
Yes. https://en.wikipedia.org/wiki/Massachusetts_health_care_reform https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...
cderwin 10y ago
It certainly could, and in fact Massachusetts implemented a similar program in the mid 2000s
dragonwriter 10y ago
> If Obamacare is repelled at the Federal level, could a state just implement its local ACA? Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. It's also likely that a repeal would be accompanied or followed by federal policies which would make state-specified versions of the ACA less practical than they are now. > what prevents California for instance of giving health coverage for its residents? California already provides state-run send healthcare beyond the requirements of the federal programs it participates in.
- vmarsy 10y ago
  > Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, what would be impractical? If a state ACA is challenged in court, couldn't they use the supreme courts rulings of Obamacare as a strong defense? Other comments here mentions that Massachusetts already had it (and I assume would likely keep it even after Obamacare is repealed), Couldn't California copy the Massachusetts implementation? > California already provides state-run send healthcare beyond the requirements of the federal programs it participates in. But I assume those state-run programs aren't providing as strong of a coverage as Obamacare was? Now would seem a good time to update it to match Obamacare?
  - toomuchtodo 10y ago
    > That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, Mandating coverage, which is basically a requirement of affordable universal healthcare. "What happens if I don't pay the fee? The IRS will hold back the amount of the fee from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee." https://www.healthcare.gov/fees/fee-for-not-being-covered/ https://www.healthcare.gov/fees/fee-for-not-being-covered/
    - amalcon 10y ago
      Massachusetts did this in the program that Obamacare was modeled after, so clearly that's not (currently) illegal at the state level. The fee structure is different (just a missed deduction on the state taxes, not a separate monthly charge), but it still works.
      - toomuchtodo 10y ago
        I'm not saying it can't be done; I'm saying its a pain in the ass due to the political climate in the US. Apologies that wasn't clear.
kasey_junk 10y ago
https://en.wikipedia.org/wiki/Massachusetts_health_care_reform https://en.wikipedia.org/wiki/Massachusetts_health_care_refo... Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan).
- chimeracoder 10y ago
  > Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan). And we (in Massachusetts) are still trying to figure out how to pay for it. Massachusetts already had an incredibly low uninsured rate to begin with, which helped, but even then, the costs have been unsustainable. In each of the last three governor's races, the major issue on both candidate's platforms were their respective promises to find a way to pay for it all. Most recently, MA elected Charlie Baker, a former health insurance executive who has promised to find a way to make the program sustainable.
kgrin 10y ago
To some degree, yes - Massachusetts did that, in fact, and the plan there (that was signed, somewhat ironically, by Mitt Romney) is very very similar to the ACA. There are a lot of details, though, that make this complicated and not necessarily viable for all states (MA is both relatively wealthy, has relatively wealthy neighboring states, and has a somewhat unusual healthcare market).
rayiner 10y ago
> If Obamacare is repelled at the Federal level, could a state just implement its local ACA? No, because the Constitution mandates that states engage in a "race to the bottom." California could create their own healthcare program, but they couldn't preclude neighboring states from free-riding on their system by not having their own healthcare and enjoying lower taxes, and simply driving across the border when they needed care.
- Mindless2112 10y ago
  Just charge out-of-state patients the difference -- like how out-of-state tuition is more than in-state tuition at state-run universities.
  - rayiner 10y ago
    Out of state tuition at public universities is charged pursuant to exceptions to the dormant commerce clause that don't apply to welfare programs like healthcare.
    - Mindless2112 10y ago
      I'm sure there are bright enough legal minds in California to construct something that both legal and effectively equivalent for healthcare.
  - int_19h 10y ago
    "Shapiro v. Thompson (1968) considered the constitutionality of a state law that established a one-year residency requirement for welfare recipients. The Court struck down the law, finding it a violation of the "right to travel" (really, more the right to migrate). The Court said it had "no reason to ascribe the source to any particular constitutional provision," relying instead on the "fundamental rights" prong of equal protection analysis. In a subsequent case, the Court upheld residency requirement for in-state tuition benefits. In so doing, the Court distinguished Shapiro, which it said involved access to "basic necessities of life." In Zobel v Williams, the Court, 8 to 1, struck down a Alaska scheme that distributed royalties from the state's mineral revenues to state residents based on the length of state residency. Residents received $50 in benefits for each year they lived in Alaska. Various justices offered three different reasons for invalidating the plan. Finally, in Saenz, the Court breathed new life into the Citizenship Clause of the Fourteenth Amendment in finding that clause to be violated by a California law that set lower welfare benefits for newer residents than for long-term residents. The Court says the clause "does not allow for degrees of citizenship based on length of residence." (http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresidents.htm http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresi...)
nugget 10y ago
The Federal Government funds >90% of California's medicaid expansion which is the vast majority of newly-insured people under the ACA. 1 in 3 Californians now receives free health care under Medi-Cal, California's medicaid program. If the Feds withdrew medicaid expansion funding I don't think California could afford to keep it up themselves without extremely painful tax hikes (which it may already be slating for future pension bailouts).
- DrScump 10y ago
  1 in 3 Californians now receives free health care under Medi-Cal Look at that again, people. That's not just subsidized coverage; it's free coverage, for over 13 million... and that was before adding free coverage for those here illegally. Does this strike people as a long-term sustainable model?
huherto 10y ago
One problem may be that sick people would move to California just because of this. May be it is not a big problem if enough states do it. The extra load would be shared among several states. Smaller states may have not big enough to have a healthy market.
- noobermin 10y ago
  If you're poor enough to not afford healthcare how can you be rich enough to hop state boundaries?
  - shimon 10y ago
    A bus ticket is way less expensive than cancer treatment. Of course, it's not like every sick person will travel to a handful of states, but of course some people will move in order to get health insurance. If only a few states implement it, they will thus bear a higher share of the costs than if the whole country participates.
    - noobermin 10y ago
      Perhaps I am assuming too much, but any sane universal health care system will require you to be a resident of a state for some period of time. Otherwise, then people will just hop a bus as you said and run the state dry. Assuming that it requires residency, that requires that the sick person quit their job, find a place in the new state to live and work for say a year or two while staying alive with a dire sickness. It's not just a bus ticket that you need to relocate, there are many more significant costs associated with a move. And even in that case, unless the state is already overcrowded, this is essentially a way to grow the state's residency and thus it's tax base.
      - rbcgerard 10y ago
        you mean like the current ACA which allows people to buy coverage after being diagnosed (since they have to accept pre-existing conditions?)
bb88 10y ago
You mentioned California, so I am using that as an example. They would find it difficult to do such a thing. Other states with more reasonable approaches to taxes, might find it easier, but I'll denote the challenges specifically in California. First off, keep in mind the following: 1. Populous states like California pay far more in Federal Taxes than they get in return in return. [1] 2. California must have a supermajority in the legislature to approve taxes. [2] So it's a complex issue, but simply put, there's not a lot of wiggle room for California to add billions of dollars of health subsidies to it's state budget. Medicaid is basically one big government subsidy for the poor. When the Obamacare medicaid expansion goes away, millions will fall out of health insurance instantly. [3] As for the managed plans, subsidies were used to make the plans more affordable to the taxpayers which made it easier for people to afford coverage. [4] It's possible that some things may stay in tact like the pre-existing condition clause, but unfortunately the health insurance companies won't be able to cover everyone without the individual mandate. [5] Also, before the pre-existing clause, health care companies were rejecting people for health insurance with pre-existing conditions. [6] The options besides subsidies for California are: 1. Government mandate of costs at doctors offices and hospitals, which may become illegal if the US Congress votes against it. 2. Government mandates on the behavior of insurance companies. This might drive many insurance companies out of California. Neither appear to be a viable option. 1: https://goo.gl/paMrzG https://goo.gl/paMrzG 2: https://en.wikipedia.org/wiki/California_Proposition_13_(1978) https://en.wikipedia.org/wiki/California_Proposition_13_(197... 3: https://www.healthinsurance.org/california-medicaid/ https://www.healthinsurance.org/california-medicaid/ 4: https://goo.gl/JVkaN0 https://goo.gl/JVkaN0 5: https://goo.gl/STciup https://goo.gl/STciup 6: https://goo.gl/Uoljhx https://goo.gl/Uoljhx
- DrScump 10y ago
  California must have a supermajority in the legislature to approve taxes. [2] That's not true, and your referred source doesn't say that. That said, the Democrats have full supermajorities now.
  - bb88 10y ago
    Source [2] does in fact say just that: Quote: "In addition to decreasing property taxes and changing the role of the state, the initiative also contained language requiring a two-thirds (2/3) majority in both legislative houses for future increases of any state tax rates or amounts of revenue collected, including income tax rates and sales tax rates."
cdr 10y ago
Some states have tried, including Colorado in the most recent election via ballot measure, but the plans have been resoundingly defeated at the ballot. I doubt even Massachusetts's current health system would pass a vote if it were on the ballot today. I suppose that could change depending on how badly the republicans muck things up.

by vmarsy 10y ago

acchow 10y ago

> This would give California and SV an even bigger advantage regarding what is described in Sam's post. Btw, San Francisco has essentially had universal health care since 2007 (via Healthy San Francisco), though it doesn't cover non-residents on I-94. It would be interesting to see if citizens and permanent residents represented a high proportion of founders in SF than, say, Silicon Valley.

elastic_church 10y ago
> The program is open to city residents, ages 18 and up, whose incomes and net worth are low but who do not qualify for other public coverage, and who have had no insurance for at least 90 days. Ah the classic "if you are middle class F U" program

Judson 10y ago

Yes. https://en.wikipedia.org/wiki/Massachusetts_health_care_reform https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...

cderwin 10y ago

It certainly could, and in fact Massachusetts implemented a similar program in the mid 2000s

dragonwriter 10y ago

> If Obamacare is repelled at the Federal level, could a state just implement its local ACA? Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. It's also likely that a repeal would be accompanied or followed by federal policies which would make state-specified versions of the ACA less practical than they are now. > what prevents California for instance of giving health coverage for its residents? California already provides state-run send healthcare beyond the requirements of the federal programs it participates in.

vmarsy 10y ago
> Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, what would be impractical? If a state ACA is challenged in court, couldn't they use the supreme courts rulings of Obamacare as a strong defense? Other comments here mentions that Massachusetts already had it (and I assume would likely keep it even after Obamacare is repealed), Couldn't California copy the Massachusetts implementation? > California already provides state-run send healthcare beyond the requirements of the federal programs it participates in. But I assume those state-run programs aren't providing as strong of a coverage as Obamacare was? Now would seem a good time to update it to match Obamacare?
- toomuchtodo 10y ago
  > That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, Mandating coverage, which is basically a requirement of affordable universal healthcare. "What happens if I don't pay the fee? The IRS will hold back the amount of the fee from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee." https://www.healthcare.gov/fees/fee-for-not-being-covered/ https://www.healthcare.gov/fees/fee-for-not-being-covered/
  - amalcon 10y ago
    Massachusetts did this in the program that Obamacare was modeled after, so clearly that's not (currently) illegal at the state level. The fee structure is different (just a missed deduction on the state taxes, not a separate monthly charge), but it still works.
    - toomuchtodo 10y ago
      I'm not saying it can't be done; I'm saying its a pain in the ass due to the political climate in the US. Apologies that wasn't clear.

kasey_junk 10y ago

https://en.wikipedia.org/wiki/Massachusetts_health_care_reform https://en.wikipedia.org/wiki/Massachusetts_health_care_refo... Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan).

chimeracoder 10y ago
> Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan). And we (in Massachusetts) are still trying to figure out how to pay for it. Massachusetts already had an incredibly low uninsured rate to begin with, which helped, but even then, the costs have been unsustainable. In each of the last three governor's races, the major issue on both candidate's platforms were their respective promises to find a way to pay for it all. Most recently, MA elected Charlie Baker, a former health insurance executive who has promised to find a way to make the program sustainable.

kgrin 10y ago

To some degree, yes - Massachusetts did that, in fact, and the plan there (that was signed, somewhat ironically, by Mitt Romney) is very very similar to the ACA. There are a lot of details, though, that make this complicated and not necessarily viable for all states (MA is both relatively wealthy, has relatively wealthy neighboring states, and has a somewhat unusual healthcare market).

rayiner 10y ago

> If Obamacare is repelled at the Federal level, could a state just implement its local ACA? No, because the Constitution mandates that states engage in a "race to the bottom." California could create their own healthcare program, but they couldn't preclude neighboring states from free-riding on their system by not having their own healthcare and enjoying lower taxes, and simply driving across the border when they needed care.

Mindless2112 10y ago
Just charge out-of-state patients the difference -- like how out-of-state tuition is more than in-state tuition at state-run universities.
- rayiner 10y ago
  Out of state tuition at public universities is charged pursuant to exceptions to the dormant commerce clause that don't apply to welfare programs like healthcare.
  - Mindless2112 10y ago
    I'm sure there are bright enough legal minds in California to construct something that both legal and effectively equivalent for healthcare.
- int_19h 10y ago
  "Shapiro v. Thompson (1968) considered the constitutionality of a state law that established a one-year residency requirement for welfare recipients. The Court struck down the law, finding it a violation of the "right to travel" (really, more the right to migrate). The Court said it had "no reason to ascribe the source to any particular constitutional provision," relying instead on the "fundamental rights" prong of equal protection analysis. In a subsequent case, the Court upheld residency requirement for in-state tuition benefits. In so doing, the Court distinguished Shapiro, which it said involved access to "basic necessities of life." In Zobel v Williams, the Court, 8 to 1, struck down a Alaska scheme that distributed royalties from the state's mineral revenues to state residents based on the length of state residency. Residents received $50 in benefits for each year they lived in Alaska. Various justices offered three different reasons for invalidating the plan. Finally, in Saenz, the Court breathed new life into the Citizenship Clause of the Fourteenth Amendment in finding that clause to be violated by a California law that set lower welfare benefits for newer residents than for long-term residents. The Court says the clause "does not allow for degrees of citizenship based on length of residence." (http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresidents.htm http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresi...)

nugget 10y ago

The Federal Government funds >90% of California's medicaid expansion which is the vast majority of newly-insured people under the ACA. 1 in 3 Californians now receives free health care under Medi-Cal, California's medicaid program. If the Feds withdrew medicaid expansion funding I don't think California could afford to keep it up themselves without extremely painful tax hikes (which it may already be slating for future pension bailouts).

DrScump 10y ago
1 in 3 Californians now receives free health care under Medi-Cal Look at that again, people. That's not just subsidized coverage; it's free coverage, for over 13 million... and that was before adding free coverage for those here illegally. Does this strike people as a long-term sustainable model?

huherto 10y ago

One problem may be that sick people would move to California just because of this. May be it is not a big problem if enough states do it. The extra load would be shared among several states. Smaller states may have not big enough to have a healthy market.

noobermin 10y ago
If you're poor enough to not afford healthcare how can you be rich enough to hop state boundaries?
- shimon 10y ago
  A bus ticket is way less expensive than cancer treatment. Of course, it's not like every sick person will travel to a handful of states, but of course some people will move in order to get health insurance. If only a few states implement it, they will thus bear a higher share of the costs than if the whole country participates.
  - noobermin 10y ago
    Perhaps I am assuming too much, but any sane universal health care system will require you to be a resident of a state for some period of time. Otherwise, then people will just hop a bus as you said and run the state dry. Assuming that it requires residency, that requires that the sick person quit their job, find a place in the new state to live and work for say a year or two while staying alive with a dire sickness. It's not just a bus ticket that you need to relocate, there are many more significant costs associated with a move. And even in that case, unless the state is already overcrowded, this is essentially a way to grow the state's residency and thus it's tax base.
    - rbcgerard 10y ago
      you mean like the current ACA which allows people to buy coverage after being diagnosed (since they have to accept pre-existing conditions?)

bb88 10y ago

You mentioned California, so I am using that as an example. They would find it difficult to do such a thing. Other states with more reasonable approaches to taxes, might find it easier, but I'll denote the challenges specifically in California. First off, keep in mind the following: 1. Populous states like California pay far more in Federal Taxes than they get in return in return. [1] 2. California must have a supermajority in the legislature to approve taxes. [2] So it's a complex issue, but simply put, there's not a lot of wiggle room for California to add billions of dollars of health subsidies to it's state budget. Medicaid is basically one big government subsidy for the poor. When the Obamacare medicaid expansion goes away, millions will fall out of health insurance instantly. [3] As for the managed plans, subsidies were used to make the plans more affordable to the taxpayers which made it easier for people to afford coverage. [4] It's possible that some things may stay in tact like the pre-existing condition clause, but unfortunately the health insurance companies won't be able to cover everyone without the individual mandate. [5] Also, before the pre-existing clause, health care companies were rejecting people for health insurance with pre-existing conditions. [6] The options besides subsidies for California are: 1. Government mandate of costs at doctors offices and hospitals, which may become illegal if the US Congress votes against it. 2. Government mandates on the behavior of insurance companies. This might drive many insurance companies out of California. Neither appear to be a viable option. 1: https://goo.gl/paMrzG https://goo.gl/paMrzG 2: https://en.wikipedia.org/wiki/California_Proposition_13_(1978) https://en.wikipedia.org/wiki/California_Proposition_13_(197... 3: https://www.healthinsurance.org/california-medicaid/ https://www.healthinsurance.org/california-medicaid/ 4: https://goo.gl/JVkaN0 https://goo.gl/JVkaN0 5: https://goo.gl/STciup https://goo.gl/STciup 6: https://goo.gl/Uoljhx https://goo.gl/Uoljhx

DrScump 10y ago
California must have a supermajority in the legislature to approve taxes. [2] That's not true, and your referred source doesn't say that. That said, the Democrats have full supermajorities now.
- bb88 10y ago
  Source [2] does in fact say just that: Quote: "In addition to decreasing property taxes and changing the role of the state, the initiative also contained language requiring a two-thirds (2/3) majority in both legislative houses for future increases of any state tax rates or amounts of revenue collected, including income tax rates and sales tax rates."

cdr 10y ago

Some states have tried, including Colorado in the most recent election via ballot measure, but the plans have been resoundingly defeated at the ballot. I doubt even Massachusetts's current health system would pass a vote if it were on the ballot today. I suppose that could change depending on how badly the republicans muck things up.