When I was reading the material on the anti-federalists, I immediately thought of Obamacare.
One of the many critics of Obamacare is that the states do not have enough discretion in implementing Obamacare and various safety net plans. For instance, state governments have almost no control over Medicaid, making Obamacare the predominant healthcare available to those citizens. This, ultimately, disables the representatives of the state from “[knowing] the minds of their constituents and the people [knowing] their representatives.” (Kaminski and Leffler 3) Obamacare may not work the same for everyone, and there should be other options out there for everyone.
On the other side, the argument is for each state to submit state plans to the Centers for Medicare and Medicaid Services (CMS) that specifically outlines all the state’s needs. After that is submitted and approved by the federal bureaucracy that runs Medicaid, the state should then be covered by Medicaid. This means that the state should then be fully covered by Medicaid if the plan is approved by the federal bureaucracy that runs Medicaid, right? Wrong.
Just because a state is covered by Medicaid, it doesn’t guarantee that you will get healthcare. The federal government forces states to control Medicaid spending, which is rendering them broke. This is causing them to have to cut provider rates. Medicaid pays so little compared to other private insurances that doctors are dropping out of the program all together. This, basically, eliminates the safety net program guaranteed by the federal government. The anti-federalists feared a large republic would “deteriorate into monarchy” and would the diverse population resulting in “constant clashing and disorder.” (Kaminski and Leffler 3) In states like California, this diversity between state and federal government highlights this clashing and disorder with the lack of healthcare options for citizens.
Not only are citizens not receiving healthcare, the government is creating all the rules and regulations for Medicaid. For example, nursing homes are completely funded by Medicaid. This means that toilet paper, tissues, nutrition, etc. are all funded by Medicaid. How meals are given out and how the quality of life of a patient are then determined by CMS and, subsequently, all rules and regulations as follows. The state has little room to experiment with the current system in place and in order to amend or change a rule or regulation, a state must submit a waiver. This process could take years. This is not the best example of state interests being met by a large government, as the anti-federalists fear with a new constitution.
As of right now, states have some ideas on how to run, and even improve, current Medicaid programs. Some states would like Medicaid patients to have complete control over the funds so that they may become more cautious with their use, some want to basically convert it into more of a private insurance, and some want to penalize unnecessary ER use from patients. However, none of this is attainable given the current federal Medicaid rules. What is currently in play is what has to stay in play. Although it seems as if states play a major role in healthcare regulation, they are merely puppets. The CMS are the ones actually in control. This sounds exactly like what the anti-federalists feared: a strong centralized government that lead to clashing of opinions and under representation of small states.