By Joseph Antos and James C. Capretta
The New York Times, April 4, 2019
By backing a flimsy, state-initiated lawsuit to throw out the entirety of the Affordable Care Act, President Trump has made himself and Republican candidates in 2020 vulnerable to attacks that they want to take health insurance away from millions of people.
Yet not all is lost on the issue for Republicans. Many Democrats, by rushing toward a single-payer Medicare for All plan, are being pulled along by ideological yearnings instead of practical realities. Medicare for All would upend all current public and private insurance arrangements, including employer coverage for about 180 million people. Further, even the sponsors admit these plans would require significant middle-class tax increases.
What that means is that the door is open for a responsible Republican plan to improve the nation’s mixed public-private health system. If the party’s leaders were so inclined, they could take advantage of the Democratic overreach by embracing reforms that would build upon what exists and make it work better. Such a conservative reform plan would look something like this:
A Medicaid Compromise
Republicans should embrace a compromise that allows the non-expansion states to expand Medicaid eligibility to 100 percent of the federal poverty line instead of 138 percent as required by the A.C.A. The expansion states could stay at 138 percent if they wanted to. States should also be given more flexibility to run the program with less federal interference in return for accepting limits on overall spending.
Instead of creating a new insurance program, Congress should make it easier for people to enroll automatically. Eligible individuals could be enrolled in a no-cost plan with the option of paying a premium for more generous coverage.
Some states have lowered premiums in the individual insurance market by providing reinsurance to insurers or organizing high-risk pools that protect against losses stemming from the very high-expense cases. By lowering the risk of large losses, insurers are able to reduce premiums for all of their customers.
Strengthening Competition and Market Incentives to Control Costs
The most difficult and pressing issue in health care is high and rising costs. Republicans say the answer is stronger market incentives, but they need to back up the rhetoric with concrete reforms. To begin, Congress needs to place an upper limit on the tax break for employer-provided health care to promote more efficient health insurance. The Federal Trade Commission should more aggressively examine business deals that create de facto monopoly providers in local health care markets. Both parties want Medicare to emphasize value instead of volume in the provision of care. To achieve that goal, beneficiaries need clear information on the cost of their care, and they should share in the savings when they choose high-quality, low-cost providers. More broadly, consumers should be able to see the all-in prices they will pay for high-volume procedures. Finally, Republicans should encourage more competition among drug manufacturers and limit abuses that extend monopolistic pricing for years beyond what patent law is supposed to provide.
Republicans keep searching for a politically safe silver bullet that slays Obamacare and yet leaves everyone happy. That plan doesn’t exist.
But voters aren’t looking for a miracle. They would settle for solid progress. It’s time for Republicans to become the party of responsible health care.
Joseph Antos is a scholar in health care and retirement policy at the American Enterprise Institute. James C. Capretta is a resident fellow at the institute.
Comment, NYT Pick:
By Don McCanne, M.D.
The authors are noted experts in health policy and understand the pros and cons of both market-oriented reform and public financing systems, yet they are driven by their conservative ideology as they dismiss single payer Medicare for All as representing “ideological yearnings.”
The Democrats already made the mistake of yielding to conservative ideology in crafting the Affordable Care Act based on the Heritage model, believing falsely that Republicans would cooperate. Now these authors want to salvage this highly flawed model by merely tweaking it.
Setting ideology aside, the single payer Medicare for All model actually would achieve the goals of true universality, comprehensiveness, accessibility, administrative efficiency, equity, and would use public policies, including tax policies, that would make health care affordable for all of us.
Nobel Laureate Kenneth Arrow showed us that market ideology does not work in health care. Even Nobel Laureate Friedrich A. Hayek, revered by conservatives, in “Road to Serfdom” states, “Nor is there any reason why the state should not help to organize a comprehensive system of social insurance in providing for those common hazards of life against which few can make adequate provision.”
It’s time to throw out stale arguments based on ideology, and enact and implement a program with proven effectiveness – single payer Medicare for All.
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