Avik Roy released a health reform proposal yesterday, published by the Manhattan Institute (full pdf). I am not going to go all post-modern literary critic on this (only deconstruct), in part because a lot of it lines up nicely with things I have been writing about/calling for over the past few years, in search of a political deal that could move the policy ahead. For example, I called for replacing the individual mandate and federalizing the dual eligibles and buying low income persons into exchanges in December of 2010! (these are “cousins” of what Avik proposes). My more fully fleshed out “next step health reform” version came in my book in 2011. Again, it is not hard to imagine a deal between what Avik and I wrote.
Perhaps most importantly is the tone, that acknowledges that policy deals are available. However, politics have been standing in the way.
As Avik puts it:
One of the fundamental flaws in the conservative approach to health care policy is that few—if any—Republican leaders have articulated a vision of what a market-oriented health care system would look like. Hence, Republican proposals on health reform have often been tactical and political—in opposition to whatever Democrats were pitching—instead of strategic and serious.
The biggest question facing Avik’s proposal is not in policy terms or what supporters of the ACA will think, but whether any elected Republicans will be willing and able to shift gears and begin trying to move health reform ahead instead of simply looking for what helps in the next election. My hope (and cautious expectation) is that the answer is yes, after the 2014 election.
Two things I especially want to encourage in reform discussions that overlap with what Avik has proposed and that I have previously proposed as part of a North Carolina-specific reform/waiver approach within the ACA (p. 6-7):
-
Imagine a Medicaid waiver in which the cost of the dual eligible beneficiaries (those covered by Medicare and Medicaid) are federalized to reduce the perverse incentives inherent with two payers of care; state cost savings could be used to expand insurance coverage
-
Pilot a premium support approach to the setting of premiums for Medicare advantage plans in North Carolina, two to three years after we begin a State-run insurance exchange with the Medicaid waiver/BHP expansion I suggest
There is lots of health policy to be banged out in those two points that I have suggested, but the need for LTC reform is a crucial issue that I have written much about. And the current political stalemate in which exchanges are the panacea in the Medicare program, and the worst thing ever in the ACA-and vice versa, is silly.
I will have more detailed comments later, but I commend Avik for offering this plan, and think there is a plenty to like in the proposal itself, as we look for the next step in health reform.
Barry_D says
Richard Mayhew over at Balloon Juice reviewed this (http://www.balloon-juice.com/2014/08/14/reading-the-manhatten-institute-so-you-dont-have-to-part-1/)
Short version: It's garbage.
Second take - the Manhattan Institute has a history of garbage.
Third take - Avik Roy has a history of garbage (if you want, I'll post links).
Don: "I am not going to go all post-modern literary critic on this (only deconstruct), in part because a lot of it lines up nicely with things I have been writing about/calling for over the past few years, in search of a political deal that could move the policy ahead."
I'm sorry, but what 'political deal' are you talking about? Something cut with the same GOP which (a) reneged dozens of times and (b) passed dozens of repeal bills?
byomtov11 says
Don,
I read the linked document, but see no plan.
I see a lot of claims about the wonders of what it will accomplish, but aside from some vague references to state-based exchanges (what ACA was intended to have anyway) and insurance regulations there is not much to get a hold of there.
I'm not actually surprised. Some of Roy's previous writing on health was not exactly accurate.
JamesWimberley says
You have to get half-way through the ES of Roy's plan before you come to the part about sunsetting Medicare by raising the eligibility age by four months each year.
Avik Roy's problem is to get Republicans interested in actual health care policymaking as opposed to grandstanding against Obamacare. I would guess after their likely 2016 electoral defeat rather than the likely 2014 tie.
Don's problem is to get Democrats interested in nonexistent bipartisan bargains. The base is more interested in single-payer in Vermont than dismantling Medicaid. The Adullamite refusal by GOP governors to set up state exchanges led to the unintended success of healthgov - a building block of a more, not less, national system.
I am staggered by Roy's description of the problem to be solved:
It all depends on a pattern of ever-rising costs that is now breaking - led by Medicare, the most socialist part of US health provision apart from the VA. Roy's not unhinged, but he hasn't got his feet on the ground either.
Don Taylor says
You can't pick the other side's tactics/goals, etc and i don't think it is long run sustainable for health reform to be one party's thing. I realize many on here think I am hopelessly optimistic that we will someday get to a deal, but I think we have to try….in large part because of the problems with the ACA (though it is clear that the health exchanges are fairly stable, certainly as compared to what seemed possible last Thanksgiving).