Political Animal


July 09, 2012 3:46 PM Are Federal-State Grant Programs “Progressive?”

By Ed Kilgore

At TAP today, Scott Lemieux raises several previously under-discussed points about the concurrence of Justices Breyer and Kagan in the portion of the majority opinion that invalidates the Affordable Care Act’s sanction of total withdrawal of Medicaid dollars from states refusing to implement the Medicaid expansion. Aside from speculating as to why progressives aren’t (aside from the occasional Glenn Greenwald) accusing the two “liberal Justices” of betrayal, Lemiuex wonders if they were forced or at least encouraged to cut some sort of deal with the Chief Justice to secure the fifth vote to uphold the rest of ACA:

[T]here was a unique strategic element to this case that gave a powerful reason for Kagan and Breyer to join Roberts. Roberts’s belated decision to uphold most of the ACA, first of all, probably compelled Kagan and Breyer to show some cross-ideological comity to encourage him to stay in the fold. Admittedly, we cannot know for certain what effect the strategic votes of Kagan and Breyer had on Roberts. (I hope that the Supreme Court leakers will find some time to tell us whether Breyer and Kagan changed their votes after conference.) Given that it’s unlikely that there was explicit horse-trading involved, it may always be unknowable. But this is where the first point becomes crucial. Liberals had nothing to lose by joining Roberts on this one issue, so they had no reason not to try to cement his belated switch.

Scott goes on, naturally, to deplore the consequences of the Medicaid part of the decision, and Lord knows I’ve written my share of lamentations on that subject.

But there is a more basic point that progressives need to consider beyond the immediate result in this case: is there some general point of progressive principle supporting the maximum degree of coercive power for the federal government in federal-state grant programs? Yes, beyond the Medicaid expansion, there are reasons to fear that this decision will soon spur lawsuits to invalidate “coercive” provisions in environmental laws and other major policies that rely on federal-state partnerships. But are these partnerships themselves inherently progressive?

Recall that the major purpose of the Medicaid expansion itself (as has been the case in a host of previous federal “improvements” to Medicaid) was to reduce the vast disparities in Medicaid coverage in the various states, a major source of the “uninsured” problem to begin with. Is the real offense to progressive values the enhanced ability of states to reject federal limitations on their control of Medicaid policies, or the original structure of Medicaid giving them that control in the first place? Certainly the decision to make a Medicaid expansion a key element in ACA was attributable in part to the desire to build on the most important existing program providing health insurance to those without meaningful access to private insurance (or to Medicare or VA), and in part to reduce, albeit not by that much, the federal costs associated with covering the uninsured. But as some state-level progressives have been arguing for decades, the continued reliance on federal-state programs to address national policy objectives comes at a considerable price of its own: the inevitable interstate inequities, a loss of accountability, and public confusion as to which level of government a central public function “belongs.”

As regular readers know, I’m personally not sold on a single-payer system (though I’m increasingly attracted to it), and don’t think just expanding Medicare to cover everybody necessarily makes sense or is the political silver bullet its proponents often assume it is. But the eventual goal of getting rid of the current patchwork system of government health insurance programs ought to be pretty fundamental to progressives. Would anyone designing a universal national system of health insurance (whether it’s single-payer or public-private) assume it was a good idea to make state governments central to its administration? Maybe, or maybe not. But the Court’s decision ought to make us reconsider whether the crutch of intergovernmental programs, so often utilized for short-sighted reasons, really ought to be the central instrument of progressive governance.

Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.


  • c u n d gulag on July 09, 2012 4:33 PM:

    I'm from the school of thought that everything regarding health care be handled by the Federal Government.

    Reagan was the one who detached a lot of federal payment for, and oversight of, rrograms, and gave them back to the states.

    That's one of the reasons highways are great in some states and suck in others.
    That's why a lot of things are fine in some states, and atrocious in others.
    And the good ones are almost all in the Blue states, and the sh*tty ones are the Red ones.
    Odd, that... No?

    And don't get me started on what's happened/happening in education!

  • paul on July 09, 2012 4:43 PM:

    Going from 100% to 0% is pretty darn coercive. And the feds have a history of using that coercive power for things that are not always obviously brilliant, e.g. resetting speed limits, changing the drinking age, implementing intrusive ID requirements...

  • SecularAnimist on July 09, 2012 4:58 PM:

    Ed Kilgore asked: "Would anyone designing a universal national system of health insurance (whether its single-payer or public-private) assume it was a good idea to make state governments central to its administration?"

    Umm, gee, I don't know, Ed -- maybe Canada would?

    "Canada's national health insurance program, often referred to as 'Medicare', is designed to ensure that all residents have reasonable access to medically necessary hospital and physician services, on a prepaid basis. Instead of having a single national plan, we have a national program that is composed of 13 interlocking provincial and territorial health insurance plans, all of which share certain common features and basic standards of coverage ... Roles and responsibilities for Canada's health care system are shared between the federal and provincial-territorial governments. Under the Canada Health Act (CHA), our federal health insurance legislation, criteria and conditions are specified that must be satisfied by the provincial and territorial health care insurance plans in order for them to qualify for their full share of the federal cash contribution, available under the Canada Health Transfer (CHT). Provincial and territorial governments are responsible for the management, organization and delivery of health services for their residents."

    Ed Kilgore wrote: "As regular readers know, Im personally not sold on a single-payer system ..."

    Perhaps you would be if you learned some basic facts about how a successful single-payer system, like Canada's Medicare, actually works.

  • Doug on July 09, 2012 6:36 PM:

    I would imagine that the mix of Federal/state in regards to Medicaid and other programs is basically because that's the only way they could be sold.
    What politician doesn't like to have a bit more patronage to hand out?

  • Ben on July 09, 2012 7:34 PM:

    Since the Eisenhower Administration, the federal government has been more friendly than the median state towards historically disadvantaged and systemically marginalized groups. Larger federal intervention has meant increased freedoms for many citizens from the Deep South to the Industrial Midwest.

    The postwar liberal consensus manifested itself among national policy elite, but often skipped state-level government: this is why federal courts stepped in to reform state plantation-model prisons. This is why federal troops were called to Little Rock.

    Federal grants-in-aid are traditional carrots that pair with more coercive sticks. If you're a fan of national norms coming to bear on local blights, you should be a defender of grants-in-aid from a historical perspective.

  • Roy Davis on July 10, 2012 3:11 AM:

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  • LaFollette Progressive on July 10, 2012 11:45 AM:

    From a progressive standpoint, the problem with using federal dollars to twist states' arms is not so much the coercion itself, but the fact that coercion is necessary at all to achieve a national health care policy.

    The problem is federalism itself.

    Some policies should be set at the state or local level, others (like regulating the health insurance market) should be handled at the national level. The perverse effect of our ridiculous system, which gives states "sovereignty" over aspects of policy they aren't either fiscally or structurally equipped to handle, is that it leads so naturally to coercion and arm-twisting as the default setting for federal-state relations that the federal government ends up using coercion to influence decisions that actually SHOULD be made at the state level. Like K-12 education policy.