On December 16, 2010 I wrote a post that began:
While the rhetoric around health reform has been incendiary from day one, in policy terms, a compromise between Democrats and Republicans using the outline of the Affordable Care Act (ACA) has always been available. The two primary problems with the health care system are costs and lack of coverage. The ACA does pretty well on the second, and is a start on the first, but much more is needed. It will be very hard to get a handle on health care costs, and we will likely only succeed in doing this if both parties are on board.
I then proposed the outlines of a deal:
- Federally guaranteed catastrophic coverage implemented via Medicare
- Private insurance sold in state-based exchanges for gap amounts if individuals desired more coverage, with income based subsidies
- Federalizing the dual eligible Medicaid costs, and moving over time to buy low income persons into subsidized private gap insurance, thus transitioning the low income portion of Medicaid over time
- ending the tax preference of employer paid health insurance; make all subsidies explicit
I refined these ideas in an e-book called Balancing the Budget is a Progressive Priority in August, 2011, and revised it after the failure of the Super Committee to replace the sequester in a version published by Springer in April, 2012. The book claimed that we didn’t need short term cuts in discretionary spending for a sustainable long run budget, but instead needed the next (and the next and so on) steps on health reform, and an increase in taxes collected as a percent of GDP to at least 21% given the movement of the Baby boomers into Medicare, Medicaid and Social Security.
There are many ‘yeah buts’ about the above-outlined deal. I am unsure what the ideal health system would be, because what I think what we most need is a political deal so that we can move ahead with the policy, focusing on the goals of expanding coverage and addressing costs. We will never do the hardest work asking whether health spending is ‘worth it?’ without both sides bearing responsibility for it.
So why do both sides need a deal?
- For Liberals and Progressives, universal coverage is the holy grail, not just of health policy, but of all public policy. Conservatives don’t have a similarly focused top health policy interest, and that makes finding a deal more difficult (lengthy debate between myself and Jim Capretta touching on this). We need a deal because the continued Republican opposition to the ACA, which is made more effective by the Supreme Court’s decision making the Medicaid expansion voluntary, thwarts achievement of our goal of universal coverage (that I also believe to be a precursor to having a hope of addressing costs/wasteful spending).
- Conservatives need a deal because they have no politically viable health reform plan embraced by elected Republicans, and without one they have no hope of what they claim to be their pre-eminent policy objective of smaller government, because the biggest long run spending side issue is health care costs. Keep in mind that Gov Romney ran on a platform of doing nothing to Medicare for 10 years (rescind House Budget cuts that mirrored the ACA; premium support starting in a decade). Further, the Republicans have controlled the House of Representatives for 28 months now, and have voted to repeal Obamacare numerous times, but never seem to get around to the replace part. Last month they couldn’t even muster the votes for a modest risk pool plan.
I obviously thought we needed a deal a long time ago, and my proposal to move away from Medicaid’s current structure has been the part of the ‘deal’ that has gotten me the most heat from my friends (here is a less grand deal). However, the discussion of the recent Medicaid study has reinforced my belief that the political warring over health reform crowds out our ability to make policy based on evidence. Every study is now just another salvo in a never ending political war around Obamacare, without the offer of a credible alternative. I am a strong supporter of the ACA which expands Medicaid, and would be happy to implement and revisit it when we know more. The passage of the ACA has put the entire health care system into play, and whatever final result we land on, its passage will have been the first step.
However, it is clear to me that both sides would benefit from a political deal to allow us to take the next steps with at least some of the heat removed from the conversation.
cross posted at freeforall
With all due respect, I don’t agree that the GOP needs a deal. GOP leaders are completely comfortable with the lack of universal coverage, and they don’t in actuality really care about the “size” of government — they mostly just don’t want it to help poor people. If it is a huge government that protects the rich, that is just fine with most of the leaders. (I do think some of the little people are somewhat sincere about “small government.” So what?)
Ergo, they have absolutely no motivation to do *anything.* And meanwhile, fighting ACA is fun for them.
Agree wholeheartedly. The premise of the discussion is that both sides want to implement policy, and that premise is demonstrably false. I think Rachel Maddow is correct in her opinion, based on plenty of evidence, that the Republicans are post-policy. The politics is everything for them, and they have no interest in governing at all, let alone in governing with Democrats. Republicans will oppose any conceivable deal that is supported by Democrats. If Democrats come around to supporting a Republican proposal, Republicans will change their minds and oppose that as well.
Show me a Republican counterexample, and I’ll show you a Republican who will lose the next primary.
Oh, god, here we go again, Dr. Taylor seeking rainbows and fairies in the Republicans’ middens. I call dibs on any unicorns he finds there.
The ACA was always going to be a complete mess; Why else was implementation pushed out a couple of election cycles, if not to keep the voters from connecting cause and effect, and taking vengeance promptly?
This being the case, and Democrats owning this cluster-f*k in fee simple, why should Republicans accept the invitation to become complicit? There’s only one thing Republicans want to do about the ACA, and that’s REPEAL it, try to restore the system the ACA was designed to break.
It’s your mess, own it.
“Try to restore the system the ACA was designed to break”. What system? The one in the 1950s television ads for washing machines and vacuum cleaners, with little John and Jane playing in the yard with Rover the dog, and Dr. Trusty holds Mom’s hand and prescribes sugar pills for her cancer?
Oh, we do own it Brett. The President embraced the “Obamacare” name and won the election
rather handily (including the popular vote for the House, though idiosyncrasies of
geographic distribution of voters allowed the Republican majority to survive).
Romney, in his ungracious way, said that Obama had used it to buy votes - but heck,
isn’t giving large numbers of people something that makes their lives better a
perfectly reasonable way to govern ?
And that was before most of the beneficial aspects of the law kicked in.
“And that was before most of the beneficial aspects of the law kicked in.”
You know, that’s been the Democratic line for, what, three years now? “Any day now the public will start liking it.” And for three years now it’s been unpopular.
No, Congress does not delay implementation for a couple of election cycles on things they expect to be popular, and they were certainly right in this case.
“No, Congress does not delay implementation for a couple of election cycles on things they expect to be popular, and they were certainly right in this case.”
Congress enacted the basic Social Security law in 1935. The first benefits weren’t paid until 1940.
You don’t know much about this stuff, do you?
Well, Brett, they *did* start liking it. As I pointed out, Obama embraced
it and won the election convincingly. And while the ACA polling numbers may not
look great, that’s because 40% of people (aka Republicans) want to rip it up,
and 15-20% want to go further and have real socialized medicine, or at least
Medicare for everyone.
I think you’re wrong about the reasons for delayed implementation: some of it
was a necessary period to set up a pretty complex scheme (one reason to prefer
Medicare for all …), and some of it was to do with the arbitrary 10-year
window for budget projections, which distorts policy in appalling ways (e.g.
Bush’s arbitrary schedule of inheritance tax changes). If everyone on the
Republican side wants to congratulate themselves on being “certainly right”
about this, I look forward to seeing how the 2016 elections play out, with
tens of millions of people getting ACA-subsidized insurance (and possibly a
notorious Democratic healthcare wonk on the ticket …)
Some polling here showing very high popularity for many elements of ACA (which
of course would go away if Republicans succeeded in repealing it):
http://healthsprocket.com/hs/node/7899
Don’s tireless search for rational conservatives reminds me of SETI.
US national politics is a zero-sum game - “both sides would benefit from a political deal”
is an absurdity. And while you say that Republicans “claim” to be interested in shrinking
the government, their actions of the last 10 years indicate that the claim is bunk.
They love tax cuts; they love spending on the military and all forms of corporate welfare;
they created Medicare Part D; and when Obama has offered them several deals with large
spending cuts and small tax increases, they utterly rejected it every time. Their
revealed preference is a) against tax increases; b) against deals; and c) don’t care
about spending in general.
It’s also evident from their approach to immigration policy that they will cater to their
short-term concerns (primary challenges from right-wing crypto-racists) even when it puts
them on a long-term path to extinction (demographic trends suggest that the growing Latino
electorate will turn Texas Democratic in 2020 or 2024, leaving no plausible EV majority
for a Republican candidate).
Your deal might or might not be good policy. But it ain’t going to happen.