• Health policy on November 6, and on November 7, too

    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.

    • Tie has previously pointed out the similarities between the IPAB and the Patient Choice Act so that is one possibility.

      There might be bipartisan support for reducing the tax preference for employer-sponsored benefits. As someone who is generally liberal, I would support that if some of the revenue were used to help people purchase insurance. A second concern would be retaining the protections for people who might be pushed into the individual market in ACA, especially those for people with preexisting conditions and strengthening those for older Americans who are not yet eligible for Medicaid..

      Allowing Medicare Advantage companies to reduce premiums instead of spending most of the money they make by beating the benchmark on new services might be another possibility.

      Increasing transparency is another area of possible agreement. A previous article on TIE noted that courts have sometimes forced insurance companies to pay for unproven care. Making it easier for people to understand what insurance policies mean by experimental treatment and easier for them to estimate the chance of their being affected by some of the exclusions might also make it easier for insurance companies to win in court when they deny coverage.

      Malpractice liability reform that addresses both over payments and under payments (people who are the victims of malpractice who are too sick and/or poor to sue) might appeal to both liberals and conservatives.

    • There is a long-standing view of history that views change in the structue of a nation’s social contract as being related to ideas or related to a human champion. It is a difficult challenge, even though I lean toward ideas or new knowledge as the essential trigger for change. I also believe that our healthcare industry is over involved with its connection to the economic mandate for healthcare as opposed to the social mandate with its connection to justly equitable values for the health care of each citizen. To redress the imbalance between the economic and the social mandates for healthcare, a new nationally sanctioned institution will be required. This institution will require a Congressional Charter and should foster the priorities necessary to support the local initiative to assure that Primary Health Care is uniformly available, justly accessible, reliobly effective and equitably efficient for each citizen.

      I propose NATIONAL HEALTH as described at: http://nationalhealthusa.net/ It assumes that any improvement in our nation’s cost of healthcare may not possible without enhanced Primary Health Care neighborhood by neighborhood and community by community. I also believe that the values, commitments and skills for this transfomation already exist at every level of the healthcare industry. The ideas for the Blog come many sources but are integrated by the life-long research of Professor Elinor Ostrom.
      During the month of May in 2013, I propose that the organizational Meeting for the Board of Trustees of NATIONAL HEALTH be scheduled by Congress. The Blog has a proposed Strategic Development Plan (under the GOALS Page). Its over due! May of 2013 would occur one year after Professor Ostrom died from cancer.