For the Nation:
You know, nowhere is the dysfunction of our original compact more clear than in the discussion of the "opt out" Public Option. Lets go back to first principles: we have, until recently, had a system of largely private insurer based healthcare in which large and larger for profit private insurance companies offer group plans to large "groups"--generally employer based--and individual plans for individuals and families who don't get employer sponsored group membership. That has been "state based" because, as I understand it, when you allow for profit insurance companies to sell policies across state lines state AG's discovered that they were even more likely to rip off the consumer than when you simply let them gouge people within state lines.
Surrounding this basically for profit system, in which individuals and companies pay into the plans while they can/while they are employed and then attempt to handle their health care needs through insurance is a not for profit, government run, safety net for 1) the elderly and 2) the chronically sick and poor, and 3) people who need dialysis and kidney transplants. In other words, for a very long time, the government and the tax payer have acted as a kind of safety valve for the neediest--the elderly who have chronic "pre-existing" conditions like, say, life and the the very sick and very poor. This is precisely what hurt the Post Office, of course. We allowed the growth of for profit Federal Express and UPS to cream off high paying business mail services and left the Post Office to handle the more costly and difficult task of providing low cost delivery to everyone else. In effect the government has stepped in and saved Private Business from the actual cost of carrying through on their promise to insure workers/citizens and to guarantee health care coverage by saying "if you want to refuse coverage to an elderly person, or raise premiums beyond reason, we'll catch some number of the people you throw overboard."
But of course people don't need insurance, or health care coverage, only for the portion of their lives when they are employed. In fact, as it turns out, they really need it especially when they are unemployed and unable to pay the premiums. In states where very few people are covered during their working life times and their early youth to middle age (*cough* red states, union busting red states *cough* ) people routinely get to the age of medicare coverage much sicker than they do in blue states with good health benefits through employment. The cost of lifetime coverage simply gets shifted towards the latter end of life when the government steps in and picks up the tab.
Well, that's basically what is going to happen, geographically speaking rather than temporally, with the opt out provision for states. This was an integral part of discussions, as I remember them, about Welfare back in the day. We always heard about how people from low welfare states would move to get welfare in high welfare states. We hear about women going across state lines to get abortions. We hear about citizens travelling to Canada to get treatment and drugs. We hear about "high tax" citizens going across state lines to get the cost benefit of "low sales tax" states. But suddenly we hear nothing about the individuals whose state's opt out of the public option? I'd suggest we hear nothing about it because a) fears of mass population movement for welfare purposes were wildly overstated by anti welfare people b) people just don't have the option of moving and c) its not sociall and politically convenient to talk about widening the gap between modern, humane, welfare states and the old former slave states and territories.
Another reason we hear nothing about individuals and families voting with their feet to get into states with a good standard of living and a good safety net because individuals and their health care needs have been largely ignored in this debate. Who has brought up the needs of the uninsured and the underinsured? The DFH's, the fringe, MoveOn, and the rest of the leftist weirdos. The stories that these groups have collected reveal the odd fact that people need health care coverage regardless of their income level, regardless of their employment situation, and regardless of the profit margins of their insurers. In fact, generally speaking, people need more health care as they get progressively less profitable for insurance company coverage. They need more health care as they take on "risks" like getting raped, or assaulted in domestic violence, or while living sexually, or having children, or getting older. Sometimes, as we now know, they need more health care when they take on the "risk" of being "fat" as a breast fed four month old. Individuals and families in low coverage states will continue to get low coverage and continue to need high coverage regardless of the compromises that Harry Reid and the Democrats are willing to make on their behalf. This is going to be a regional "compromise" that echoes the compromise over slavery that poisoned the first half of our life as a country.
The semi independence of our States has been the bane of this country since its inception. But never more so on questions of civil rights, women's rights, and health care as a right. What gives Republican Senators, or Centrist Democrats, the right to declare that individual citizens in their states can't choose a low cost, permanent, form of health care? Do they have the right to opt their states out of Social Security, or Medicare, or the tax system generally? Why is this a decision that gets made at the state level? Its not as if states are guaranteeing coverage to their citizens, as they do with a public school system. Its as though states were refusing to set up a free public school system and insisting that the only educational options were private, high cost, religious schools.
Its time for the Democrats to grasp that national initiatives must be national in scope. Health care choice is the perfect place for that argument to be made. Individuals require health care coverage regardless of their age, station, or location. They need progressively more health care coverage as they age, or the sicker they get. Allowing some states to "opt out" of the struggle to cover all citizens is identical to allowing private, for profit, insurance companies to cherry pick high paying/low cost, healthy people and while shoving the sickest off onto Medicare and Medicaid. Just as we are trying to prevent a situation in which the neediest have to go to expensive emergency rooms we should be actively working to prevent the situation in which the neediest drive across state lines to establish residency to get more generous benefits than their own states will cover. Not because we don't want to see everyone covered but because we don't want red states to free ride on the rest of us. This is so obvious a point that you can expect no one at the top level, the White House say, to make it.