A response to Avik Roy and me

You’ll find a different response to the Avik Roy post I wrote about on the xpostfactoid blog. The author, Andrew Sprung, takes up a debate I mostly dodged by pointing out that Avik and I had gone rounds on such things before. (What’s the point of doing so again?) Andrew’s update at the end of the post addresses my “world weary stance.” Since it’s the sort of thing that might have appeared in the TIE comments* were they not closed, I thought I’d share it here. (Hint: Worthwhile comments can still appear on TIE. Just email them to me.)

First, a ground pre-prepped for de facto compromise has been laid — in the state exchanges. […] [S]tarting in 2017, states can apply for waivers by submitting alternative plans that purport to meet the ACA’s coverage benchmarks (in 2011, Obama pronounced himself willing to move the waiver start date to 2014 []).  On the Medicaid front, the Obama administration has shown itself willing to accept a wide range [of] conservative experiment[s]; the same will doubtless prove true for the exchanges if any GOP-run states want to try.  The ACA might be viewed as a multi-state laboratory waiting to happen — with no need for knock-down-drag-out fights in Congress. Governors willing to deal in good faith can work quietly with HHS — or hand-in-glove, if a Republican becomes president in 2017.

Second:  facts should eventually overwhelm polarized “debate.”  Privatizing Medicaid will cut costs and/or improve care, or it won’t.  A state exchange that gives prominent place to HSAs and perhaps rejiggers essential benefits or incorporates catastrophic options into the exchanges will create a viable market, or it won’t.  Within a few years, there will be a lot of state experiences to compare. If results are ambiguous, states can continue with diverse systems, as they already do on many fronts.

One last thought. Productive compromise may be possible on issues one side doesn’t “own” reform — e.g., in bipartisan legislation afoot to replace Medicare’s Sustainable Growth Rate (SGR) and transition provider payment away from fee-for-service.  Perhaps lobbying will corrupt the process or ideology will rear its head and poison it.  But there’s at least a possibility that both sides can commit to a plan that unskews provider incentives to some degree.

Andrew is more optimistic that facts will overwhelm polarization than I am. Oh, if only it were so simple. We rarely (if ever) agree in advance what will signal success, and most policy experiments offer myriad means of assessment. Even a given outcome can be measured differently. Lies, damned lies, and statistics! Dueling studies and interpretations are almost guaranteed. Feel free to come back and prove me wrong.

But the author is correct that there is more flexibility already in the ACA than we often hear about. By no means do I expect that conservatives (or even liberals!) find that flexibility sufficient. Nor need they. At a minimum, however, is that its existence suggests that even “the architects” of the law recognized that it was a foundation upon which to build, not the end of reform and experimentation. This, it seems, is what Avik was also suggesting, though perhaps to a different degree.

* Andrew tweeted me as much.


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