Steve Parente’s Health economics and policy: towards the undiscovered country of market based reform (IHFE, 2012) is dense with quotable goodies. Here are some of them:
- “The hallmarks of ACA ranging from insurance exchanges, to the individual mandate, to pay or play policies for employers, high risk pools and the partial capping of the tax exclusion were all supported as market based solutions by Republican officials for nearly 30 years. The only exception was a federally controlled Medicaid expansion which the Supreme Court in June 2012 determined to be coercive and left to be an option for Governors to decide to implement. As a result, there are many issues in ACA implementation Republicans can inform just as easily as Democrats.”
- “To measure outcomes adequately you need minute by minute tracking of implanted ‘outcome’ sensors that the best science fiction and speculative fiction writers can dream up coupled with civil libertarians going on a permanent holiday to Venus. More likely we will have cold fusion and warp drives before we have adequate outcomes based reimbursement that is a mainstream form of provider payment.”
- “Spend any time talking to health informatics experts and one finds a distinctive care delivery information technology vision where the future linked care systems are sharing data with other care systems. But these physician futurists are not running their hospitals. Those in charge of hospitals see the release of clinical data as the biggest potential malpractice liability risk in generations.”
- “As ACA grows the number of providers in the public and private insurance market, a monopsony [private] payer can gradually move their payments towards Medicaid levels for all clients very gradually over time to improve/maintain their margins and further erode the monopoly pricing power of physicians. Furthermore if newly forming ACOs/hospitals are acquiring physician practices and expect revenue at a certain level based on historic commercial payment rates, the ACOs may be in for rude awakening if payments start to migrate even a few percentage points closer to Medicaid payments compared to their original expectations.”
- “The qualification for a real plan should be either proposed legislation or a document with specific policy details to be easily developed into legislation.”
- “While the ACA has many components that may be a step backwards towards a market based solution it also has many pieces that, over time, make a market based approach inevitable particularly with the now optional expansion of the Medicaid program for states to decide.”
Putting aside any possible political motivations, it is astonishing how few conservatives embrace the ACA as non-ideal yet viable platform for more market-oriented reforms. “Repeal” is divisive. When the “replace” is just a couple of ticks away from what’s already in law it’s almost insulting. Apart from politics, there’d already be bipartisan effort on the next reform. The political requirement to remain in perpetual opposition impedes the reorientation of policy in a direction conservatives might prefer, even if not perfect. (Pro tip: Nothing is perfect, least of all legislation.)
