Gene Steuerle argues yes, that budget caps placed on total federal spending (Medicare, Medicaid, tax subsidy of private insurance) is the way to go. For one thing, he says we will never completely decide between the various approaches to cost control. Instead, we will maintain a muddled system with many mid-course corrections, likely driven by election victories of the various parties, fueled at least in part by opposition to efforts at health care cost control. And Steuerle notes that for all the heat between the sides and talk of fundamental differences, three basic questions loom over any approach to cost control.
- How should budget constraints be applied?
- Should automatic budget growth for health care programs (particularly, Medicare) finally be reined in?
- Should government health program budgets be limited even if neither side gets its way on question 1?
He notes that question 1 is the focus of most debate (think IPAB v. voucher), and any answer to this question will be politically hard (again, see comments on IPAB and town hall meetings on Ryan budget). This drives both sides to needing budget caps on federal health spending if we are to control health care costs. He says if we wait for political agreement on how to actually implement cost control (the last step, again IPAB v. vouchers for simplicity), we will never control costs, because we will never decide once and for all. So, the answer to question #3 must be yes, if we are to address health care costs. He believes budget caps that provide flexibility to implement different answers to question 1 is the way to go (and he makes a convincing case).
I especially like the reply that Steuerle makes in the comments section of his piece in a reply to Joe Antos (comments in parentheses are mine):
….I asked, but he (Joe Antos) did not answer, what one does if there is no permanent resolution of the health care debate. Right now Joe is arguing with his partner (the Dems) over how they should raise their kid, but the kid is playing in the street. To those who say we don’t know what to do, or we can’t do anything unless done my way—often those on the other side of the issue from Joe—I say we do know what to do: bring the kid in off the street.Common ground doesn’t mean agreement on everything. Removal of open-ended budgets represents the common ground element of both the Obama and Ryan plans. [emphasis mine]
The bigger difference between the Obama v. Ryan approach is that the ACA aims to address costs while expanding insurance coverage, whereas the Ryan budget does not have a strategy to expand insurance coverage. Perhaps budget caps to control federal costs and fighting out the next election (and the next, etc) over the coverage issue and the mechanism of applying the agreed upon caps is the best we can hope for at this time.