Opinion: An interstate compact for healthcare


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Published: 01-28-2024 7:30 AM

Ahmed Kutty, MD, lives in Peterborough.

The concept of healthcare as a human right and its public funding have gained steady salience in our public discourse recently, thanks largely to the 2016 presidential campaign of Sen. Bernie Sanders. Since then momentum for a national health plan has stalled at the federal level.

Several state-based legislative efforts have been attempted over the last three decades, notably with California’s Proposition 197 in 1994 and the 1992 New York Health Bill. Sadly, such state bills either got killed or after passing, succumbed to gubernatorial veto; and a few are languishing in committees of the various legislatures across the country.

Vermont in 2011 came close to the finish line, but the staggering cost projections, hyped in the media by the special interest groups, provided cover for the governor to pull the rug from under it in December 2014, even though he had campaigned arduously for it. The small size of the population and its budget versus the exaggerated price estimates for a universal public plan was pronounced as the major cause of the debacle. Scaling up to a beneficiary pool of at least five million, yielding a larger revenue base was the lesson learned, opined several leading healthcare economists.

Interstate compact, a constitutional feature dating back to the colonial period, was adopted from the 1776 Confederation document into the U.S. Constitution in 1789 under Article 1, Section 10, Clause 3. This provision allows two or more states to band together to jointly execute public projects on a regional basis and for carrying out varied functions of common interest. Geographic contiguity is not required.

Nationwide, 200 compacts exist evidencing its efficacy as a governance tool. Port Authority of New York and New Jersey, created under a 1922 Compact, remains a strong and popular entity regulating regional transportation. New Hampshire is in the Northeast Water Pollution Control Commission. School districts of Rivendell and Dresden are administered under a New Hampshire-Vermont compact. 46 member states via a compact govern driver’s licensing.

In healthcare licensure for nursing, emergency medical service personnel and practitioners of telehealth under the compact mechanism is a success story. A compact among New England states with a combined population of 5 million or more, obtainable for instance with a grouping of New Hampshire, Vermont and Maine offers a regional, pragmatic and optimally-sized vehicle for publicly financing healthcare as social insurance for all residents of the region, while continuing to keep care delivery predominantly in the private sector.

Each state passing the enabling legislation to create the Compact for Healthcare will, under an interstate healthcare commission, have a compact-wide governing board and a healthcare trust fund akin to our national Medicare Trust Fund. Funds from targeted revenues for healthcare and from general funds are appropriated and aggregated into the trust fund. Premiums, deductibles, copays and coinsurance will be replaced by a progressive healthcare tax and/or surcharge, and will result in the abolition of most out-of-pocket costs at the point of service for all residents of the participating states, for all medically appropriate care.

Congressional consent, while required, is generally granted if the goals and functioning of the compact do not infringe on federal powers. A tougher nut to crack will revolve around obtaining a Congressional waiver for merging Medicare and the federal portion of Medicaid funds into the compact trust fund. Section 1332 waiver facility available under the Affordable Care Act for state-level innovations in funding and care delivery points to a potential path forward.

A bill titled ‘An Act Establishing an Interstate Compact for Universal Healthcare’ (HB 353) sponsored by Strafford Rep. Peter Schmidt in the winter of 2023, after a Commerce Committee hearing got tabled, was put on the consent calendar and met its demise early this January. The Granite State chapter of Physicians for a National Health Plan having toiled hard on this bill, with tenacity, resilience and resourcefulness will not let the story end here.

Public support and agitating for healthcare justice from the elected officials in Concord is a necessary but not sufficient condition for gaining traction. Multipronged strategies to generate the necessary political will in our elected leadership class to stand up to the moneyed interests who have captured and commodified our healthcare system, and to do the right thing are critically needed now. Gigantic efforts at ‘for-profit privatization’ of public programs like Medicare, Medicaid, veterans healthcare, long-term, rehab and mental health care, dialysis centers and several other care-giving organizations are proceeding at a breakneck pace, mostly under the radar of public awareness.

Percy Bysshe Shelley’s line, “Rise like lions from slumber…ye are many, they are few” must inspire us to act vigorously and unfalteringly for an affordable, efficient, equitable and publicly-insured system in northern New England, carrying the potential to be the catalyst for a national plan like Saskatchewan’s was for Canadian Medicare in 1962-72.