Health care reform and ch-ch-ch-changes

This because I don't know why. Just 'cause.

Here because I don’t know why. Just ’cause.

Apologies for the title. It’s Friday. More seriously, though, there are two items on health care reform that I think are very instructive from a (mostly) practical point of view on the future of health care reform.

First, there’s Ross Douthat on “Different Kinds of Health Care Disruption:”

[…]Last week, amid the ongoing coverage of rising premiums and cancelled plans, the health care law’s defenders took a new tack, arguing that the most plausible conservative alternatives to Obamacare would involve even more disruption of existing arrangements — with the implication being, then, that Republican outrage over “rate shock “is either straightforwardly cynical or else a sign that the G.O.P. would never, ever be willing to embrace a reform that disrupts the status quo at all.

But I also think it’s useful to think about the differences between the kind of disruption that would accompany the most plausible conservative alternative to Obamacare and what we’re actually witnessing today[…]

The conservative alternative I have in mind is […] the more modest plan the American Enterprise Institute’s James Capretta has done the most work fleshing out, in which a cap on the employer deduction helps pay for a flat credit available only to those Americans who don’t receive coverage through their workplace.

I’ve arranged this selection for the purpose of my comments. Also, you should read the whole thing anyway. The end point Douthat’s arguing is that, given the conditions and context, he considers that the inevitable disruptions from any conservative health care reform could be less than we’re currently experiencing under the Affordable Care Act. Fair enough. It really is important that this engagement exists if you’re interested in further reform.

That being said, the other item you should read is Austin Frakt’s response. It’s a great summation of nearly every, too-often separated, contention with constructive conservative proposals for reform. Before I block-quote one part of the list he arranges, let me highlight a couple of recurring themes. First, details matter, as he writes, “What is catastrophic? What is affordable?” This matters very much, as anyone who has been following the health care debate can attest. Concretely answering those questions in legislation or policy can have huge, hotly contested, implications.

Second, and related, that “[h]igh risk pools are not without limitation.” Every conservative proposal has to deal with people being denied insurance for preexisting conditions. The most prevalent feature is establishing (or more accurately, bolstering) state-based high-risk pools for these ‘consumers.’ Yet beyond the efficacy of such a system, that kind of policy requires money — a lot of it — in the context of a political base that’s actively working to prevent spending a lot of money on sick Americans.

 Which segues nicely into his sixth (out of eight) point (emphasis mine):

There is no coalition for this. Just as it is wrong to say there are no conservative reform ideas, it is equally incorrect to suggest that there is a law-enacting coalition for one. True, this is in large part because Democrats control the Senate and the White House, but them’s the breaks. Having said that, Democrats are well aware of the limitations and problems with the Affordable Care Act. Some are so troubling that the administration is considering some interesting proposals that would require Congress to act. Point being, there is leverage for some negotiation on some aspects of the law.

The largest obstacle within the Overton Window for health care reform is the absence of a Republican coalition for their own ideas. Elected conservatives don’t support them. Instead they’ve voted on repealing, wholesale, the Affordable Care Act. Instead, they’ve voted to bring the general ACA framework to Medicare beneficiaries. Instead, they’ve voted to block-grant Medicaid that would effectively cut the program by millions of dollars (and people). Everything they’ve done on health care reform has reflected and reinforced an activist base that supports them.

These factors arguably run deeper than simply representing the minority status of Republicans in government. Yet the important takeaway should be, for folks on the left at least, that these types of critiques are not an effort to delegitimize serious (albeit rare) conservative health care ideas. They’re an effort to further reform which, like it or not, will depend on some form of engagement with them. For folks on the right, at some point you’ll have to recognize that doing nothing (or worse than) is not option. Disruptions are inevitable, regardless, and it might be better for everyone if we just take ownership of that fact and move on.

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