Ryan-Coburn, Ryan-Rivlin and ACA

Ezra Klein has been writing that many of the policy attributes, mechanisms and challenges facing the Affordable Care Act (ACA) are similar to those of the Ryan-Rivlin plan and what Klein calls Ryan-Coburn.  Ryan-Coburn is The Patients’ Choice Act (PCA) that was introduced into the last Congress, and is what I think was the most comprehensive Republican health reform proposal put into bill form.  Co-sponsor Sen. Richard Burr (R-NC) has said the PCA will be reintroduced in this Congress.  A few quick thoughts about the PCA and the ACA:

  • As Reihan Salam notes, the PCA would completely end the tax preference of employer paid insurance; the ACA has a back-door capping of this subsidy via the Cadillac tax which is delayed until 2018.  A compromise would cap the tax exclusion that PCA wants to end, and do it sooner than 2018.
  • The tax credit in the PCA [Update: I erroneously wrote ACA here; this applies to the Patients’ Choice Act, the Republican plan] could be spent in an exchange in which pre-existing conditions were banned, or on any plan sold outside the exchange; insurers would not have to provide policies in the exchange, and those sold outside of exchanges could use medical underwriting.  This is possibly the difference Rep. Ryan says exists between ACA exchanges and how he would do it, but if so I think it presents problems.  I wrote this in August, 2009:

“Because the tax credits can be used to buy plans both inside and outside of the state-based exchange, there is a danger that only the sickest patients will seek coverage via the exchange, since coverage cannot be denied. If this happened systematically, it could result in death spiral whereby only poor risks are included in exchange-based plans. However, the Plan notes that exchanges “shall develop mechanisms to protect enrollees from the imposition of excessive premiums, reduce adverse selection, and share risk.”” (quote original, emphasis added now)

Specificity about what those mechanisms would be are needed to be able to evaluate the proposal fully, and there is a lot of policy to be fleshed out in that short highlighted sentence.

  • The PCA included the creation of a Health Services Commission to broadly apply cost effectiveness research that I described this way in August, 2009:

“The most intriguing aspect of the Act is the creation of a Health Services Commission, to be run by five commissioners appointed by the president and confirmed by the Senate. The purpose of the commission is to “enhance the quality, appropriateness, and effectiveness of health care services through the publication and enforcement of quality and price information.”

Here is a detailed post running through Title VIII of the PCA (pages 206-215 of the bill) that would have created the Health Services Commission.  Don’t take my word for it, read it for yourself.  Keep in mind that the PCA was introduced in May, 2009, around one month before the first House Committee reported out a bill. So, the most comprehensive Republican plan actually proposed a much stronger cost effectiveness board prior to the IPAB which is now so politically controversial. This fact and the later rhetoric used against the IPAB by opponents of the ACA is ironic at best.

If we could focus on the policy outside of the politics (which seems impossible) a deal has long been in the wide open.  If we could agree to a political compromise on coverage (would rolling acute care Medicaid into exchanges bring along Republicans?; if yes, count me in) we could then focus on costs, which will take us the next 30 years to get straight.  If we could just focus on the policy….

Update: added some links.  Another update: Reihan Salam with more. Update: 3/25-fixed error that is noted above.

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