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.
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comments here mentions that Massachusetts already had it (and I assume would likely keep it even after Obamacare is repealed), Couldn't California copy the Massachusetts implementation?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?
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."
The fee structure is different (just a missed deduction on the state taxes, not a separate monthly charge), but it still works.
You wouldn't just copy and paste "IRS" into the state law that a state might decide to create. You would use the state's taxing authority.
Yes, state sanctions don't generally sting as much.
But each state would have to independently decide, with its own constituents, if it could economically offer subsidized health care for all of its residents.
Many states already have some form of parallel subsidized/free health care system for certain segments of the population. Like their school teachers and their children as an example.
Anyway, hope that helps.
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.
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).
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.
Ah the classic "if you are middle class F U" program
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.
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/newresi...)
Smaller states may have not big enough to have a healthy market.
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.
1 in 3 Californians now receives free health care under Medi-Cal
Does this strike people as a long-term sustainable model?
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 2: https://en.wikipedia.org/wiki/California_Proposition_13_(197... 3: https://www.healthinsurance.org/california-medicaid/ 4: https://goo.gl/JVkaN0 5: https://goo.gl/STciup 6: https://goo.gl/Uoljhx
California must have a supermajority in the legislature to approve taxes. [2]
That said, the Democrats have full supermajorities now.
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."
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.