For the next nine days, Americans will finish the dogfight of the 2012 election. In health policy, this dogfight is, and ought to be, focused on the huge moral and ideological differences between the two coalitions represented by President Obama and Governor Romney.
Democrats support the principle of (near-) universal coverage. The central claim on this side of the aisle is that every American, in every state, deserves access to affordable health insurance, and that substantial federal dollars and regulatory authority should be devoted to subsidizing low- and moderate-income citizens and those with high current or predicted health costs to acquire such coverage. In sheer dollar terms, the Affordable Care Act is the most progressive measure since the great society. It transfers roughly $200 billion annually down the income scale to provide health coverage and care. ACA also institutes a variety of measures, which I won’t discuss in detail here, to help finance expanded coverage. Within other domains of social insurance, Democrats support the continuation of a defined-benefit structure for Medicare, and a similar defined benefit structure supporting both state governments and individuals within the arena of Medicaid, with the federal government bearing the lion’s share of the burdens and risks associated with rising health costs.
Republicans pledge to repeal and replace ACA. With varying degrees of explicitness, they reject ACA’s expansion of the social insurance compact, which Paul Ryan has called a “new entitlement we didn’t even ask for.” In ACA’s place, Republicans propose a more modest, decentralized alternative whose central specified features are HIPAA-like protections for the continuously-insured. To simplify a complex subject–and to fill in some fine print Republicans haven’t cared to specify in the campaign debate–they support shifting Medicare over time from a defined-benefit to a premium support, defined-contribution structure. Here insurer competition and the exercise of market choices by individual recipients are given central roles to control costs. Republicans support more radical transformation of Medicaid. Republican budgets and the Republican platform would block-grant and markedly cut federal contributions to Medicaid, providing states with greater operational flexibility, but shifting significant costs and risks onto lower levels of government and individual recipients.
These are genuinely vast differences. Democrats would spend more money to guarantee near-universal coverage. Republicans would spend less, but would leave tens of millions more people uninsured. TIE readers must decide for themselves before next Tuesday which of these two visions of American social provision and health policy they wish to embrace.
But what about November 7? What shall we do then? However the election is decided, I hope that policy experts and advocates on both sides find a way to more constructively cooperate when the campaign is done. I should add that I’m a pretty partisan figure myself. Yet one thing we’ve learned over time within our polarized and often-dysfunctional political system: Health policy is too large, too complex, too frightening, and too costly for one party to impose its vision or to carry the political load.
In at least a few areas, I see some real possibilities for bipartisan compromise. These will be the subject of my next post. For the moment, though, I want to hold my cards close to the vest. I want to hear your ideas for policy areas and proposals that might attract real bipartisan support? Fire away.
