In a NEJM Perspective piece, economist and AEI Scholar Joseph Antos recommends not “repeal and replace” but “delay and modify” (my words, not his).
Absent a miracle, the country will still face crushing budget deficits when the next president takes office. A Republican president, backed by a Republican Congress, would be wise to delay enrollment in the health insurance exchanges, using the time and money to develop a more targeted plan that closes off open-ended subsidies for health insurance and gets the economic incentives right. A Democratic president would do the same thing out of necessity — but it would take longer.
A president who backs such a move would be telling uninsured Americans to keep waiting, the insurance industry it’s not getting more customers, the pharmaceutical manufacturers they’re not getting more sales, and the hospital industry it’s not getting help with the uncompensated care problem. I can’t see it happening this way.
However, I am skeptical that policymakers will get more serious about cost control in the near term. The law has about a ten-year fuse on cost control (ACOs happen sooner, but the Cadillac tax doesn’t kick in until 2018 and the IPAB can’t recommend provider payment rate changes until 2020). In the interim, there are standard ways for a president, and Congress, to appear to address a budget problem. That’s what ten-year budget gimmickry is for.* I’m not saying budget gimmickry is the right thing to do. I’m saying it’s what they will think of first.
But beyond that, if anything like “delay and modify” were really attempted, what we’d actually get is “delay and more delay.” We’re not going to solve the cost control problem before substantially addressing the uninsured problem. Think I’m wrong? Get AHA, AHIP, and PhRMA to say so.
* Do readers get how the ten-year budget is gamed or do I need to post on it? In brief, keep promising savings or revenue later in the ten-year window to pay for whatever budget-busting program you want right now.