Where are health care reform's defenders?
The bill crafted in the Senate and signed into law by President Obama was a health care policy wonk's dream, containing nearly every public health, prevention, and cost-control idea floated across the pages of Health Affairs and the New England Journal of Medicine over the last ten years. In the months leading up to passage of the Patient Protection and Affordable Care Act, the Commonwealth Fund and the Kaiser Family Foundation filled my email inbox with studies justifying reform.
Yet last week, after the Republicans seized control of the House and pledged to repeal or prevent the law from going into effect, I heard nothing.
The legislation was also a Christmas morning stocking stuffed with goodies for the special interests. Yet where was PhRMA, now that it has had its donut hole filled? Or the Association of Health Insurance Plans, which backed the legislation until it opposed it, but still gets its ultimate reward -- 20 million new customers through a mandate that makes everyone buy its members' products or pay a penalty? One searches the news pages in vain for comments from these inside-the-Beltway lobbying powerhouses.
Progressive bloggers were not much better. They stumped for the individual mandate, the tax on high-cost plans, for rational discussions about end-of-life care and other controversial elements of reform, which only stoked the fires of the Tea Party rebellion. After Tuesday? Silence.
I take as my ur-text a column in Sunday's Washington Post by Ezra Klein, a blogger-turned-mainstream journalist (like myself) whose rapid ascent to card-carrying member of the punditocracy was a direct result of his willingness to master and communicate the arcana of policy issues like health care reform. I cheer his rise. He's young, smart and progressive.
Yet on the Sunday after the election, he ignored health care reform while doubling down on big tax policy ideas that stand no chance of passage. If you think the Republicans had a field day calling health care reform a government takeover of one-seventh of the U.S. economy (a complete lie), what do you think they would do with his recommendations that the Democrats (because there would be few if any Republican votes for any of these ideas) back total repeal of the health insurance deduction and the home mortgage deduction, and slap a new tax on carbon?
What was especially disheartening about his column was that it ignored solid rejoinders for the coming debate over Social Security and Medicare, which, as it happens, can also be framed as tax issues. Both programs' long-term fiscal stability would be substantially enhanced (and in Social Security's case, made secure) by extending the payroll taxes to all unearned income (right now, dividends, interest and capital gains are excluded from Medicare and Social Security taxation) and to every bracket (right now, people who earn over $106,800 a year do not have to pay additional payroll taxes for Social Security).
Okay, there's no Republican votes for that either. But as long as we're not living in the real world where election results matter, why not take on something immediately relevant, especially with President Obama's National Commission on Fiscal Responsibility and Reform a month away from issuing its report?
The coming months will be trying times for health care reform's defenders. There will be votes on total repeal, which will probably pass the House. Republicans will try to remove funding from key elements of the bill (see this article in Sunday's New York Times and my article, which appeared Monday morning in The Fiscal Times).
President Obama signaled his willingness to compromise on non-essential parts of reform when he said during his post-election press conference that Congress should repeal the hated provision requiring businesses to fill out a 1099 form for every expenditure over $600, a feeble attempt to raise money by cracking down on tax scofflaws. It only succeeds in adding paperwork to the vast majority of honest small businesses.
The president and his advisers should be thinking bigger than that. The first thing Democrats in the House should do when Congress reconvenes in January is jump on board legislation that would repeal the individual mandate. After the insurance industry stabbed them in the back during the election season, they owe those companies nothing. When the insurance industry cries out that it will have to raise rates to cover the uninsured who show up on their doorsteps after 2014 demanding low-cost coverage for pre-existing conditions, the Democrats can respond that they'll cross that bridge when they get to it.
The worst case scenario at that point is that insurance companies will have to go to 50 state-based exchanges to document precisely how much the cross-subsidy costs before passing it along in the form of higher rates. A transparent public accounting of the transferred costs for the free-riding uninsured would be a good thing.
Repealing the mandate will also moot the federal court challenges to reform filed by 20 or so Republican state attorneys general and private groups. The mandate is the only element of the law that makes it vulnerable, and given the judicial activism of the Roberts court, why chance having the whole bill voided for a non-essential provision?
Another provision the Democrats could add on to their “repeal” bill would be elimination of the tax on high-cost plans, which doesn't go into effect until 2018. There will be plenty of time to debate health care tax reform once the exchanges are up and running.
Repealing those two measures will take all the steam out of Republican efforts to kill reform. While picking on the mandate and the Medicare "cuts" were nothing more than election season demagogy, Republicans were not dishonest when they said they philosophically oppose the overall thrust of the bill. They remain committed to a vision of reform articulated by Sen. John McCain during the 2008 election. They want employer vouchers, insurance plans that cover catastrophic care only, and high co-pays and high deductibles -- all of which are designed to make health care more market driven by making consumers have "more skin in the game."
In my view, it's an impoverished view of how to hold down health care costs because it will have disastrous health consequences. People left to their own devices do not have the time or sophistication to sort out what preventive and routine services are most consequential to their long-term health.
More significantly, it will fail at holding down costs. People in emergency situations or facing chronic or serious illnesses (the 80 percent of all health care expenditures attributable to just 20 percent of the population) are in no position to act other than as passive consumers of decisions made by their providers. Most of those decisions are wise. Some are pound-foolish from health care system perspective. You're sick. Your doctor is telling you what to do. Do you want to make those decisions based on your own personal pocketbook considerations?
Reform of the health care delivery system, which is begun in the reform bill, remains the best hope for getting health care costs under control while simultaneously improving overall health. Transferring success in the pilot projects contained in the law to the broader system is the most humane way of achieving the $500 billion in Medicare savings contained in the legislation.
The mandate and the tax on high cost plans have nothing to do with any of that. In the spirit of compromise, they should be the first things to go.
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