Across State Lines

One of the GOP's ideas for killing reforming health care is to permit insurance to be sold across state lines. At Thursday's health care summit in Washington (transcript of part two here, transcript of part 3 here), at least three Republicans advocated it. Charles Boustany of Louisiana argued

The same goes for purchasing insurance across state lines. I'm glad to hear our Democratic colleagues agree that this is an approach that needs to be taken to promote choice and competition. But again, we feel that this bill restricts those options too much. And we think we can do it in a responsible way. I believe we probably could come together on this, but I think the existing proposals restrict it far too much.

Tennessee's Marsha Blackburn later chimed in:

Now, a lot of the people that I talk to want us to start over in this issue and they want us to give them the ability to hold insurance companies accountable. One of those ways is through very robust competition. And when you have a district like mine in Tennessee, where the bulk of our constituents are within 15 miles of the state line, the ability for those individuals -- who have families and live and work and have employees on the other side of the state line who shop for major purchases every day -- is to allow them to be able to make those purchases.

In yet another concession to the GOP, President Obama suggested that he agreed with the concept, noting "That's something that I've put in my proposal that's actually in the Senate proposal. I think that it shows some promise." Later, he added, "I support the idea of purchasing insurance across state lines...." Fortunately, though, he cautioned

Bbut again, the one difference, as I understand it, and the reason you're not supporting the approach that we take, is what we say is there should be sort of a minimum baseline benefit, because if not, what ends up happening is you get a company set up in Nevada -- let's assume there were no rules there, there are no protections for the woman who's got breast cancer; they go into New York, they offer pretty cheap insurance to everybody who's healthy; they don't offer the same insurance to people who aren't so healthy or have preexisting conditions. They drain from New York all the healthy people who are getting cheaper rates, but now suddenly everybody left in New York who doesn't qualify for that cheaper plan is in a pool that's sicker, older, and their premiums go up.

So what we've said is, well, if we can set a baseline, then you can have interstate competition, but it's not a race to the bottom; rather everybody has got some basic care.

At the tail end of the forum, the President added:

what is absolutely true is that some states probably have higher mandates than others and so you can probably attribute a certain amount of the cost in a high -- a state that has more requirements for bare minimum coverage, doesn't allow drive-by deliveries or requires mammograms or what have you.

There is, as President Obama would put it, a basic "philosophical difference" here. Republicans recoil at the idea of minimum standards: they would be set by the federal government rather than individual state governments; and they would be imposed upon insurance companies and much of the party simply doesn't want any restrictions upon, or regulations on, a corporate powerhouse like insurance companies. This was highlighted in an exchange by two U.S. Representatives, Democrat Rob Andrews of New Jersey and Republican John Kline of Minnesota:

Rob Andrews: Let's take the case of a woman who has a baby by C-section, and she lives in one of the many states that say you can't be kicked out of the hospital after you've had a C-section until your doctor thinks it's time for you and the baby to go home.

Now, under the association health plan proposal, that rule wouldn't apply to that lady and her baby; that there would be no protection of her in that situation. We think, John, that there shouldn't be necessarily 51 different rules for each state, but there ought to be some minimum federal standards in these exchange to protect people in cases like that.

So I think the issue is, if we could find a way to agree, that in a case like this where a lady has a baby by C-section and has the ability to not have the insurance company get between her and her doctor, so the doctor makes the decision about when they go home, we could figure this out. And if you --

John Kline: If I could just respond to that, my friend knows very well that there are large companies today who operate under what I'm proposing for association health plans. They get a waiver, they don't have to comply with the individual mandates of all 50 states, and I don't hear people complaining about the insurance policies that they're getting from their big companies. In fact....

Certainly people do complain about the limited benefits of their health insurance; John Kline doesn't "hear people complaining" because he doesn't want to hear them. Perhaps his constituents believe it would be futile complaining to him, and it appears it would be.

But the most vivid illustration of the inadequate standards some states maintain could be found in the example given by Representative Louise Slaughter (R.-NY), who maintains

Eight states in this country right now have declared that domestic violence is a preexisting condition on the grounds, I assume, that if you've been unlucky to get yourself beaten up once you might go around and do it again.

Most people wouldn't consider domestic violence a pre-existing condition; almost no one would. Even most states- apparently 84%- don't increase rates for a woman because she has been physically assaulted. If insurance can be sold across state lines as Repub members of Congress evidently believe it should, the insurance companies aren't going to set up shop in the states with the most stringent regulations, any more than credit card companies have.

Still, as Republicans collectively shout "No!" while President Obama and Senate Democratic leaders plead (as in the old ditty, "pretty please, with sugar on top") for them to be reasonable, the goal posts get moved further and further.