Two valued community members raised good points yesterday in comments:
the blue states can build their own plans. Romneycare might be the model, and some states might try something else; perhaps some sort of single payer system. I suppose they will pretty much have to.
There’s an opportunity now in California, however. The 6th largest economy on earth and 1/6 of the US economy. Dems have supermajorities in both chambers and have the governorship. We’ve twice passed single-payer and Brown has indicated he’d support it if the finances work out. If there is going to be a widespread national privatization effort, CA now has renewed incentive to make it go. Yes, its hella complicated as Richard has noted, but CA also has the most actively managed exchange in the country, one of the most competitive health care marketplaces in the country, and some of the best health policy folks around Kaiser Family Foundation.
The big problem with both of these cases is that state healthcare policy will interact with federal healthcare policy. That means some type of waiver will be needed. That could be a major blockage.
However, the core point is very strong and very valid. Blue states if they want to take care of their own citizens while allowing the Red States to race to the bottom can do so. If there are massive high income tax cuts, there will be fiscal space from high income Blue state taxpayers to fund local social insurance programs. California has the size and the expertise to make a go at something that could work. My bet is that they would go multi-payer in a tightly regulated market and build from the fairly successful Covered California exchanges with higher subsidies and tweaked eligibility but that is a guess purely informed by speculation before my first cup of coffee.
The next big challenge is getting traditional Blue States with super majorities in the Legislature back to Trifectas by retaking governorships so experimentation can move forward with motivated stakeholders. But that is a discussion for a different day.