Canadian Constitution Blogging

I don't really have a strong view on whether or not state-level health care initiatives make sense, but I do think this element of David Sirota's typically measured critique of Ezra Klein could use a little more context:

Spend 5 minutes on Wikipedia, and you'll learn that Canada's much-vaunted universal health care system began as a provincial initiative. The provinces provided both the better political opportunities, and ultimately the better initial implementation platform that ended up launching the federal program.

Back when I was in Introduction to Canadian Politics class, I was taught that the reason for this is that Section 92 of the British North America Act of 1867 stipulates that "The Establishment, Maintenance, and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals" is one of the areas in which "In each Province the Legislature may exclusively make Laws." Much of the history of health care federalism in Canada essentially amounts to steady backdoor federalization of the nominally Province-based health care system precisely because assigning primary responsibility for these matters to the Provinces doesn't really work well in the modern context.

Comments

"Typically measured," eh? Very nice.

Posted by John | July 12, 2007 3:00 PM

This is an interesting point - but it doesn't negate my point either. Ok, so legally they had to do it provincially. That's very interesting. But that doesn't somehow undermine the point that they were ABLE to start the program and run it provincially.

That's exactly my point. It's not either/or. Just because the utopian vision is for a federal system (which, by the way, I agree is the ultimate goal) doesn't mean that states are wasting their time trying to do universal health care. They aren't. If between now and the utopia more states create universal systems, more Americans will have health care coverage. That's a good thing, and that doesn't even say anything about the fact that states moving forward creates big pressure on the feds to act.

Posted by David Sirota | July 12, 2007 3:17 PM

You took a Canadian politics class?

Posted by Reality Man | July 12, 2007 3:18 PM

Dave Sirota -- you're missing Ezra's key point. What does Ezra implicitly highlight as the key difference between US states and Canadian provinces? Which is also the source of the failure of US state health care proposals. It's the self-imposed straitjacket that makes US states very weak compared to the federal government (and compared to Canadian provinces).

Go back to your Canadian politics textbooks and look it up.

Posted by Ikram | July 12, 2007 3:33 PM

It's a question, I think, of weighing process vs. politics. Does a badly-implemented state initiative retard the overall goal? And are the odds weighed against successful implementations of state initiatives, given the existing federal and private structures? (

I'm inclined towards state-based initiatives just because they're likely to be attuned to specific demographic issues. I'd also be interested to see a state take the leap and market universal provision as a means of encouraging investment/migration.

But Canadian federalism is a very different beast, just because the powers of a provincial premier with a working majority are quite different from either a state governor or a state legislative majority, as are the powers of a federal PM with a working majority. Plus, where's the American NDP?

Posted by pseudonymous in nc | July 12, 2007 3:34 PM

As a Canadian and poli-sci grad, I'm impressed!

The Canadian healthcare system is still run to this day as 10 separate Provincial entities.

The origin comes from Tommy Douglas as Premier of Saskatchewan.

The flaw in the original BNA Act is that all of the government activities that require lots of money were assigned to the Provinces and most of the powers of taxation and revenue generation were assigned to the Federal level.

This means that education and healthcare are entirely Provincial responsibilities - mostly paid for from Federal tax revenues.

Very annoying and inefficient that is, but ammending constitutions is tricky at the best of times.

Posted by Michael | July 12, 2007 3:39 PM

Michael's comment cuts to the critical point - this is not an either/or question, as Ezra tries to make it. Both federal and state efforts are incredibly important. There's a very good case to be made that the quickest way we can get to a pretty decent universal health care system in the United States is to have the feds cut checks to the states, and have the states run/administer the programs, like Canada and like Medicaid. That is, a system FINANCED in part by the feds, and run by the states.

Again, no one is saying that's perfect. But the idea that its a waste of time for states to press ahead is just ridiculous.

Posted by David Sirota | July 12, 2007 4:00 PM

David: you haven't addressed my question. Does a failed state implementation poison the well?

Posted by pseudonymous in nc | July 12, 2007 4:03 PM

I don't think a failed state implementation necessarily poisons the well, Pseud. in NC, though I can see how GOP and health insurer spin masters would attempt to argue as such. Given the multiplicity of US states, you're likely to have at least some relatively worthwhile and efficient programs in a number of states compared to failures. So (to use an example indicative of my biases) Georgia and South Carolina have failed programs -- so what, if Massachusetts, Vermont, Maine, New York, New Jersey and California have succesful ones?

so in this sense, Sirota has a point, though mellowing out wouldn't hurt.

Posted by Ben Cronin | July 12, 2007 4:17 PM

Pseud: Its too broad a hypothetical - yes, certain kinds of failed state implementations could hurt the well, others probably wouldn't. Its too broad a question, and also, respectfully, I don't think its that relevant, because a failed federal implementation could poison the well too...but it could not. I can come up with scenarios for both.

The debate really is whether its a waste or not to push universal health care at the state level, and I say that any progressive ways to expand health care coverage are a good thing. Saying that because a perfect federal system is better than a not 100% perfect state system is making the perfect the enemy of the good, and with 18,000 Americans a year now dying because they don't have access to adequate coverage, we can't afford to do that.

Posted by David Sirota | July 12, 2007 4:27 PM

David -- Is there an obvious reason that state implementation is far more likely to fail than federal implementation?. Some handicap states suffer from that the US federal government can avoid?

See this quote by Ezra:
It’s a cruel economic irony ... that recessions rob government of the revenue it needs to cover the uninsured at precisely the moment that the most people need subsidies to get them through the lean times. And states are incapable of responding, since they, unlike the federal government, are constitutionally barred from running deficits

Posted by State-Lover | July 12, 2007 4:31 PM

Michael's wrong (or at least mostly wrong). It was Woodrow Lloyd who brought in Medicare in Saskatchewan, not Tommy Douglas.

Matthew's wrong too, but it would take a lot of space to explain it. I'd just note that *of course* they taught him that provincial autonomy is bad at Harvard. That's like learning dialectical materialism is good at Pyongyang U.

Posted by Pithlord | July 12, 2007 4:35 PM

It isn't accurate to say that health and education in Canada are mostly paid for from federal revenues. Last year Ontario (Canada's largest province), for example, had revenues of $89.1 billion (fiscal 06-07). Only $14.2 billion came from the federal government (all transfers) - provincial taxes (personal income,retail sales, corporate etc.) provided the lion's share of the province's revenue ($63.5 billion).

Ontario's spending on health is over $40 billion (the Ministry of Health and Long Term Care alone spent $39 billion in fiscal 06-07 and this does not include spending on health related infrastructure).

Nor is it correct that saying health care cannot be effectively assigned to and operated by the provinces in the modern context. It is so assigned and operated in Canada and works reasonably well.

The federal government has both maintained the universality of the system (by threatening to halt payments to provinces contemplating changes that would undermine that universality) and stifled provincial innovation (by threatening ...). Such is the nature of federalism.

Posted by Anonymous | July 12, 2007 4:47 PM

Saying that because a perfect federal system is better than a not 100% perfect state system is making the perfect the enemy of the good, and with 18,000 Americans a year now dying because they don't have access to adequate coverage, we can't afford to do that.

This is where I make the distinction between process and politics. As it stands, the politics has an odd asymmetry: a system with flaws is almost certainly still better than the status quo, and likely to be embraced as such; but to deal with the reality distortion field erected by the pharma-insurance complex, it needs to be nigh-on perfect. Individuated healthcare means that it's easy to individuate the horror stories, whereas failures in a universal system are invariably treated as indictments of the system.

Coming from the process side, I simply don't know how much financial wiggle-room is available to states, given the role of Medicare/Medicaid in providing a federal tap, and the budgetary constraints that State-Lover mentions.

So (to use an example indicative of my biases) Georgia and South Carolina have failed programs -- so what, if Massachusetts, Vermont, Maine, New York, New Jersey and California have succesful ones?

That includes a presumption of simultaneity, though. The more likely scenario is that one or two Dem-heavy states take the plunge, become national petri dishes, get all sorts of shit thrown at them, and receive the kind of concentrated reporting that private systems rarely face. Within a short space of months, elections come round, pharma/insurance money falls like manna on that state, and etc.

Posted by pseudonymous in nc | July 12, 2007 5:01 PM

Right. The Feds pay enough that the provinces can't plausibly opt out of the federal conditions, but still leave the bulk of the funding to the provinces. I don't have the romantic view of decentered federalism that Pithlord has, but in this case I have to admit that he would have a point; it's sort of the worst of both worlds. I don't have a problem in principle with detailed federal health standards but they should be better funded; if the provinces are paying for most of the I-Pod they should be able to pick more of the playlist.

Posted by Scott Lemieux | July 12, 2007 5:08 PM

The other important thing is that Saskatchewan is allowed to deficit spend, keeping the system afloat in hard times, while states aren't.

Posted by Neil the Ethical Werewolf | July 12, 2007 5:09 PM

In the old days we had the legal and political science theory of "Our Federalism" in which states could try different things and, the theory went, hit upon solutions to problems. The need (and historical push) for standardization and centralization led us away from the idea of states as social laboratories. So we got things like the Dept. of Ed., a national drunk driving standard, social security, the 55 mph speed limit and Medicare. Some of these are good, some not but a state might try something, knowing that if it doesn't work, another state might try something else. In addition, under the old fashioned idea of Our Federalism, such failures of implementation wouldn't doom the policy for decades, not that any of it will be easy.

Posted by Peter Driscoll | July 12, 2007 6:35 PM

Peter Driscoll: The problems with that kind of federalism in the modern setting, even apart from the actual policy, are twofold:

a. Any kind of state system would be in indirect competition with the other 49 states for both medical professionals (who might stand to make less in a public system) and entrepreneurs who might prefer to build their clinics or hospitals in a more 'profit-rich' environment.

b. One state would have to weather the onslaught of 50 states worth of lobbyists and industry cash: any failure (and some degree of failure will be inevitable in any system) will be amplified horribly out of proportion by an industry which fears (rightly or wrongly) that Socialized Medicine (TM) might spread and harsh their buzz.

Now, that doesn't mean it's not possible or a worthwhile goal, just that there are some signifigant structural disadvantages to a state as opposed to national approach. Of course, the relative liberalness of a given state like, say, Vermont, for example, is on the other hand a unique resource of the state approach.

Posted by Tim P. | July 12, 2007 6:57 PM

To pull back the focus from Canada to the U.S., the fact is that state-level initiatives involving employer health-insurance mandates now being contemplated in California, Illinois and Pennsylvania are likely to be killed by the federal courts because of a 1974 federal law known as ERISA that bans states from telling multistate employers which benefits they must provide. The only state with an employer mandate (Hawaii) is the only one Congress granted an ERISA exemption.

And so instead of states being the laboratories of democracy they're supposed to be, on health insurance, such experimentation violates federal law if it involves telling a multistate employer which bennies to offer.

A congressman from New Jersey named Rob Andrews supports ERISA waivers for states. No one else seems to pay attention to the fact that ERISA is a bear that will block state-level employer mandates.

Posted by Chris | July 12, 2007 7:10 PM

Tim P: You are right to point out problems, as are those who point to the balanced budget problems and the risk that the whole country might move to a state that actually had a good system. As to your first point, a state could produce more doctors if it faced a shortage and there are already plenty of state-sponsored tax incentives to induce so called entrepreneurs. As to the second point the federal government is overmatched by lobbyists already. Lets get some of that bribe money into local hands.

The basic point is that we shouldn't be afraid to let the states try a hand at improving medical care. Whther you feel as I do, that we can do better, or feel that the present system should remain, a little competition among the states shouldn't be ruled out.

As to Vermont, it is liberal but relatively poor. It's like each state, unique.

Posted by Peter Driscoll | July 12, 2007 7:17 PM

Re: The other important thing is that Saskatchewan is allowed to deficit spend, keeping the system afloat in hard times, while states aren't.

Couldn't states create some sort of quasi private company to handle health insurance, more or less off budget so deficit spending would not be a leagl issue?

Re: Within a short space of months, elections come round, pharma/insurance money falls like manna on that state, and etc.

Are the insurance companies and pharmaceutical companies opposing universal; healthcare plans in MA and CA right now? How much success are they having if they are? Also, while I expect insurance companies might fight tooth and nail if they felt they would be cut out of the deal, but I don't see pharma as having a dog in that fight (as long as rigid price controls aren't part of the mix).

Re: No one else seems to pay attention to the fact that ERISA is a bear that will block state-level employer mandates.

How about a system without such mandates? We need to move away from employer-provided healthcare anyway. And would ERISA prevent a state from levying a tax on a company that did not provide health benefits? Also, hasn't the MA plan (which includes such a tax, albeit a very small one) been approved?

Posted by JonF | July 12, 2007 7:35 PM

Couldn't states create some sort of quasi private company to handle health insurance, more or less off budget so deficit spending would not be a leagl issue?

But quasi-private companies don't get unlimited credit, either. If they run a deficit, who is going to bail them out? The state government? Well, now we're right back to assuming that the state has the resources.

Posted by Steve | July 12, 2007 7:57 PM