When States Collide

While I haven’t read the book, I’ve been interested and sometimes amused at the title, What’s the Matter With Kansas.  You see, while I live in western Missouri (or as we commonly say, “On the Missouri side”), and my health system is headquartered in Missouri, the hospital I serve is in Kansas.  As a result, I pay attention to health news from Kansas with as much attention as from Missouri.

So, I didn’t miss this news item in my local paper: “Kansas state lawmakers push for health care insurance opt-out.”  It seems that three Kansas legislators have decided that any public option offered as a part of national health care reform would be an unacceptable trampling on states’ rights.  Moreover, they fear it will become a trampling on the rights of citizens (although whether they are more concerned about individual citizens or corporate citizens - i.e., insurance companies - remains to be seen).  To that end, they want to amend the state constitution to say that any health insurance mandate, whether requiring individuals to purchase health insurance or requiring employers to provide it, cannot be enforced in Kansas.

My initial reaction to this was that these state legislators were raising this issue only in Kansas.  In fact I was uninformed.  There have been efforts in other states for months now.  They are coming from conservatives who state they’re placing a high value on freedom to choose, including the freedom to choose not to purchase health insurance.  Thus, Federal individual and employer mandates are unacceptable.  In fact, for some apparently a Federal effort to make health insurance more affordable by offering a public option in a health insurance exchange, thus creating competition for private insurance companies, is somehow coercive.  So in many places efforts are being made to change state constitutions to prevent this perceived Federal encroachment.

Now, I will say first and foremost that, even if these constitutional changes pass in some states, I don’t see how they can stand for the long term.  I have already argued that all health is public.  Indeed, we’ve seen just how public it is in our current H1N1 flu pandemic.  With this, and with any contagious disease, we have reaffirmed that we are our siblings’ keepers, at least in this.  What I do to protect myself from getting the flu also protects anyone I might infect if I get it.  For me hospital patients are the special group for concern; but it also protects the grocery clerk and the waiter and the librarian whom I encounter, and even the grocery customer and the diner and the library patron who cross paths with me.  For much of our health care, we depend on a certain “herd protection.” 

It’s also the case that economically we are our siblings’ keeper.  We all pay for one another’s health care, whether it’s through taxes or insurance premiums or through the price increases brought about by losses for unreimbursed care.  That is already the case, and it won’t be changed by the reforms currently considered in Congress – or for that matter any reforms that weren’t considered.  Nor will it be changed by an attempt to prevent some government management of the competition among insurance companies.

A consequence of both these facts is that health care, and so reimbursement (or lack of reimbursement), is a matter of interstate commerce.  I am acutely aware of this in my position.  As I said, I live in Missouri but work in Kansas.  In fact many people in the eastern counties of Kansas find their health care in institutions in Missouri.  That’s a common enough occurrence in the Kansas City area, of course; but it’s also true farther south, where the larger towns and larger institutions are east of the state line.  While I don’t know the numbers, I can only imagine that in the far western counties folks who need intensive care find it in Denver or Colorado Springs.  I would bet, too, that some in the northeastern counties find it in Omaha or Lincoln.  So, in my part of the world health care is explicitly interstate commerce.

That is a regional expression, but there are other ways.  Think, for example, of the large networks of health care providers.  Such for-profit companies as HCA and Tenet are certainly interstate companies.  So are such religious networks as Adventist and Ascension.  Now, they deal already with differences between states.  However, they might find if difficult to do business in a state if it essentially establishes a population risking unreimbursed care.

One way or another, states that allow individuals to go without insurance, through lack of an individual mandate or of an employer mandate or through some other mechanism, will necessarily place burdens on institutions in other states, and so on citizens in other states.  That seems to me ripe for a decision from the Supreme Court; but that would take years.  It might take years, too, to change state constitutions; but one can only hope that those efforts fail.  Health care issues respect our political divisions no more than the illnesses that raise issues.  Let’s hope that most of our citizens, and the legislators that represent them, will see this clearly and take responsibility, not only for their own individual health needs, but also for the needs of their fellow citizens.