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Health care policy and health care reform are back in the news in a big way. The Supreme Court is poised to hear oral arguments on the constitutionality of the 2010 health care overhaul. The Obama administration has just released guidelines for the operation of the state-based insurance exchanges that are the backbone of the law.
Gas prices have supplanted unemployment as the major attack line against President Barack Obama from Republican presidential candidates and party spokesmen and their media allies. But there is an increasingly vigorous effort to make “Obamacare” and the cuts to Medicare providers that help to finance the law central issues in the campaign and in the debate over budgets and spending bills that lay ahead in Congress.
Also on the target list is the Independent Payment Advisory Board, designed to have an independent group of health care experts set guidelines for Medicare payments, something now done poorly by Congress, with the proviso that it cannot recommend cutting benefits or increasing Medicare recipients’ out-of-pocket expenses. The House will soon vote to ax the IPAB, and attacks against it as a rationing vehicle, while patently false (unless you believe that any cut in the rate of growth of health care expenditures is rationing), are increasingly strident.
Prominent GOP lawmakers refer to the health care reform law as “a government takeover of 17 percent of the economy.” They, GOP presidential candidate Mitt Romney and their allies such as the lobby group 60 Plus Association hit the Medicare changes in the law as devastating for seniors. (Of course, Romney and the others fail to mention that the 10-year House budget crafted by Rep. Paul Ryan (R-Wis.) includes the same Medicare cutbacks to bring the budget in line while waiting for Ryan’s deferred blockbuster Medicare reform.) Tough rhetoric is tempting, to rally one’s supporters and to inflame the public, but these charges are laughable.
Start with the idea that the 2010 law is a government takeover of health care — a giant step to socialism. First a reminder: The health care reform bill is essentially the 1993 Republican alternative to the President Bill Clinton’s health care plan, crafted by the late Sen. John Chafee (R.I.), former Sen. Dave Durenberger (Minn.) and current Members such as Sens. Chuck Grassley (Iowa) and Orrin Hatch (Utah.) — not exactly a group of raving socialists. Add in the other elements of the bill, which are taken directly from the Romney plan in Massachusetts, and the fact that the law, to the dismay of liberals, did not include a public option, and the charge of government takeover rings very hollow.
Next, take a look at the Medicare plan of Ryan and Sen. Ron Wyden (D-Ore.), touted by Romney and other candidates as the free-market alternative to Obamacare.
It essentially uses regulated insurance exchanges to enable seniors to purchase health insurance, with Medicare as one option along with the private plans and with premium support for seniors. The exchanges are indistinguishable from those in the health care law, and the structure of the Ryan-Wyden plan is, as one conservative health care policy analyst told me, “Obamacare for seniors.”
That might be inaccurate in two ways. The premium support for seniors in the Ryan-Wyden plan is less generous than the premium support in the 2010 law, meaning seniors will pay considerably more out of pocket over time. Second, the Ryan-Wyden plan, unlike the overhaul, has a public option!
Nonetheless, most Democrats hate Ryan-Wyden because to praise it in any fashion would mean taking away the sting of their own attacks on Ryan and Republicans for moving “to end Medicare as we know it” — or sometimes neatly forgetting the conditional “as we know it” part.
All of these factors together leave me and others dismayed at the way the driving need to reform health insurance and health care delivery has been caught up in tribal politics, where the identity of the individual promoting or proposing a policy idea is more important than the idea itself.
If I were in the Democratic leadership, I would be tempted to propose a grand compromise: Take the Ryan-Wyden plan and apply it to everyone — insurance exchanges with Medicare as an option for all. That won’t happen, of course.
The Supreme Court may blow up all or part of the 2010 law, throwing its implementation into turmoil. Whether that happens (and there is a good chance the court will punt, putting off a decision until after the elections), if Republicans win the White House and Congress, they will move via reconciliation to repeal as much of the plan as they can. And they will discover that the “repeal” part of “repeal and replace” is a lot easier than the “replace” part.
Perhaps at that point we can do what Rep. Jim Cooper (D-Tenn.), one of the most knowledgeable and clear-headed lawmakers when it comes to health care policy, has urged — that we all check our ideology and blinders at the door to discuss how to improve the health care system.
Perhaps we can open up the debate to rational discussion on what to do about defensive medicine, about how to improve not just insurance availability but the deliverability of health care services to all, about how to deal with the vexing issues surrounding end-of-life care and drivers of health care costs such as diabetes. Perhaps we can discuss the fact that using things such as health savings accounts and requiring individuals to pay for health care services and become better consumers using market forces, while highly desirable, will not take care of the reality that most Medicare spending, and much of the spending for the rest of us, is driven by a small portion of very sick people.
Wouldn’t that dialogue be refreshing? And wouldn’t it be nice if the odds of it happening were better than infinitesimal.
Norman Ornstein is a resident scholar at the American Enterprise Institute.