May 21, 2013 •
Securing universal health insurance enrollment has been a major goal of American liberals for decades, and Obamacare aims to use the individual mandate to ensure that all Americans obtain health insurance. But as I explain in a column at National Review Online, even with the individual mandate Obamacare will fail to provide “universal coverage” for Americans, and will end up becoming just another expensive entitlement program.
In its latest assessment of the law, released in conjunction with new budget projections, the CBO indicates that the number of uninsured residents in the United States will never fall below 31 million — three million more uninsured people than was estimated for the non-mandate plan President Obama rejected — and that the insured will never be as much as 90 percent of the population.
And even that estimate is highly optimistic. It assumes that 70 percent of the population eligible for the Medicaid expansion will eventually enroll in the program. As of today, however, only 24 states have governors and legislatures that would likely agree to move ahead with expansion, and that number could easily fall as more state policymakers come to the realization that Medicaid is far too often failing its current enrollees. It makes little sense in that context to dramatically expand a program that credible independent observers believe needs significant reform.
You can read the rest of the column here.
May 3, 2013 •
In a column published today at National Review Online I point out some steps that Congressional Republicans can take to not only push back against the worst aspects of Obamacare, but also to win the public argument over the future of American health care.
For the moment, the future of Obamacare isn’t a question of legislative tactics. It’s a question of political strategy — how to build a wave of public support behind a credible program to repeal Obamacare and replace it with something far better, and how to get that sentiment to prevail at the polls in 2014 and 2016. The excesses and deficiencies of Obamacare will go a long way toward convincing the public that there must be a better way. But the congressional GOP can and should also take steps to build its case and gain the upper hand in the argument. The bill to close down the prevention fund and apply some of the savings to a high-risk pool is one small step in that direction.
You can read the rest of the piece here.
April 23, 2013 •
Yesterday, I was pleased to participate in a panel discussion sponsored by the Brookings Institution, entitled “Reforming Medicare: Fiscal Challenges and Policy Solutions.” The event was moderated by Bill Galston of Brookings and included — in addition to my remarks — presentations from Bob Reischauer of the Urban Institute, Chris Jennings of the Bipartisan Policy Center, Joe Antos of AEI, and Dr. Rhonda Randall of United Health Group.
The event was covered live by C-SPAN and can be viewed in its entirety here.
April 19, 2013 •
This week, the American Action Forum (AAF) released a white paper I co-authored with AAF’s President Doug Holtz-Eakin. The paper provides new insurance coverage and cost estimates for the Obamacare replacement plan I developed in collaboration with many other health policy analysts over the past two years. (The replacement plan was described in two published articles: the first, co-authored by Robert Moffit of the Heritage Foundation, appeared in the spring 2012 edition of National Affairs; the second, published as a white paper by the American Enterprise Institute, provided some additional details about the reform plan.)
The AAF cost estimates are encouraging. They show that a replacement plan built on a decentralized, market-based reform program can broaden insurance coverage dramatically without the massive federal power grab and mandates of Obamacare. This is an important development. It demonstrates that, contrary to the talking points of the 2010 law’s apologists, there are viable, practical alternatives to Obamacare that have the potential for broad appeal with the American people.
The emergence of AAF’s modeling capacity — the Health Economic Policy Simulation System (HEPSS) — is also an important advance. It means that a new source of credible analytical information is now available to the policy community, and more information about the cost and coverage consequences of various reform plans can only help to improve the caliber of the public debate. Moreover, the estimates produced by HEPSS will almost certainly differ from those produced by the Congressional Budget Office, the Urban Institute, and others because the HEPSS model uses different sources of data in some respects (including more extensive data on the use of high deductible health plans by employers) and because every model requires the use of some assumptions, and there’s no reason to expect the HEPSS assumptions to exactly match those used by CBO and others.Obamacare is now being implemented, but that does not mean the debate over the future of American health care policy is over. Quite the contrary. Obamacare has far too many fundamental flaws for this debate to be over. At some point, the public will be receptive to hearing about alternatives to the current law, and opponents need to be ready with a fully developed answer. The paper released today is far from the final word, but it is another step in the right direction.
April 17, 2013 •
Yesterday, I was pleased to participate in a public event at the American Enterprise Institute, focusing on the content of three papers released by AEI this week (generously sponsored by the Robert Wood Johnson Foundation). The first paper, which I wrote, is entitled “The Role of Medicare Fee-for-Service in Inefficient Health Care Delivery.” I argue in it that Medicare fee-for-service is the most important reason that American health care is inefficient, fragmented, disorganized, and costly. It will not be possible to bring about real reform without significant changes in Medicare’s basic financial incentives.
The second paper, written by Robert Coulam of Simmons College and Roger Feldman and Bryan Dowd of the University of Minnesota, examines the benefits of moving toward a competitive bidding approach for the entirety of the Medicare benefit package. Private health plans would submit bids indicating the premium they would require to provide Medicare’s statutory benefits, and those bids would be used, along with the costs of providing Medicare FFS in a region, to determine a fixed government contribution. The authors estimate that this approach would reduce Medicare’s costs by $339 billion over a decade.
The third paper, written by Joe Antos, makes the case for reforming Medicare with a premium support model, including competitive bidding. The paper cites existing models, including the Medicare prescription drug benefit, and other evidence to make the case that harnessing the power of consumer choice and marketplace competition is the only reliable way to discipline costs without harming quality.
The AEI event, which was moderated by Bob Helms, can be viewed in its entirety here. Paul Ginsburg of the Center for Studying Health System Change provided helpful comments.
April 15, 2013 •
Over at Roll Call I have a column about what Congressional Republicans rightly seeking Medicaid reform can do to deal with the challenge of managing the long-term care component of the program.
Today, states try to manage long-term-care costs and quality through regulations and supply controls, but these efforts are never a match for the cost pressures that build when services are “free” to the users — and when rising use of services increases the incomes of those providing the services.
The solution is to enlist the support of those enrolled in the program in a cost discipline effort. The starting point is to calibrate financial assistance for long-term-care services and supports to the level of disability and financial needs of a Medicaid applicant. The most severely disabled applicants — as determined by an independent evaluator — with the lowest level of personal resources should get the maximum “allotment,” set at the level necessary to cover the range of support services needed to stay in the community. Other applicants with lesser disabilities or more personal financial resources would get a percentage of the maximum allotment commensurate with their circumstances.
You can read the rest of the piece here.
April 8, 2013 •
Arlene Wohlgemuth and I have an op-ed in this weekend’s edition of the Houston Chronicle on why federal block grants are the right way forward for Medicaid reform in Texas.
On both the acute and long-term care side of Medicaid, the program suffers from the same problems as the broader health system. Third-party insurance - in this case public insurance, poorly managed by the federal and state governments - creates distance between those providing care and those receiving it.
With the freedom that a block grant would afford, the state could use Medicaid funds to offer a version of "premium support," and subsidize the purchase of private insurance for non-disabled, non-elderly enrollees, who could choose an insurance plan from a competitive field. It is through this kind of competition that costs can be held in check.
April 4, 2013 •
Over at the AEI Ideas blog my colleague Yuval Levin and I make the case that both supporters and opponents of Obamacare should agree to delay the implementation of the major provisions of the law that are now scheduled for 2014.
Everyone should now understand that, if there is not a delay, next year will be the scene of an epic disaster for American health care. The trouble started, as it often does, at the top. The president insisted on passing a reform with only Democratic support. That guaranteed large-scale public opposition, which has persisted. It also left the nation’s Republican governors less than enthusiastic about becoming the law’s enablers.
The president compounded the problem by stalling on key implementation decisions in 2011 and 2012 to avoid controversy before the election. States could not get answers to basic questions about what the law’s “exchanges” would involve or what their options were for Medicaid. And insurers even now remain unclear about the regulatory environment they will confront. With so much uncertainty, states, employers, and insurers all delayed their decision-making as long as possible too. The result is that implementation of the largest social-welfare policy change in a generation is far behind schedule.
The rest of the post is online at the AEI Ideas blog here.
March 25, 2013 •
Over at National Review Online I have a column on why Republican governors should resist the Obama administration’s Medicaid expansion, and instead seek real legislative Medicaid reform.
The GOP governors engaged in these direct negotiations with the White House are playing a loser’s game, and throwing away a historic opportunity to secure fundamental and lasting reform of the Medicaid program. Even if individual states are able to secure concessions from HHS and the White House, the “deals” they strike will be in the form of temporary and inconsequential “waivers” (the terms of which will always be subject to administration amendment and revision, too). What’s worse, these deals are no way to run a national program. Why should one state receive more favorable treatment than others? And why should the administration be allowed to “buy off” states with federal taxpayer funds in the first place?
Instead, GOP governors should withdraw from this White House game of “let’s make a deal” and instead decide, as a group, what kind of Medicaid reform to demand in return for considering broader insurance coverage. Importantly, the reforms they seek should be in the form of legislative revisions of Medicaid, not temporary “waivers.” By pursuing a legislative approach, the GOP governors could join forces with House speaker John Boehner and Energy and Commerce Committee chairman Fred Upton, who have made serious Medicaid reform one of their top priorities this year.
You can read the rest of the article online here.
March 21, 2013 •
In December last year, the Texas Public Policy Foundation released a report that I co-authored with colleagues from Leavitt Partners. The report focused on how the state of Texas should reform the long-term care components of the program to stay within the confines of a fixed Medicaid budget, such as would be the case with a block grant.
This week, TPPF released a follow-on report outlining the broader reform strategy for the Medicaid program. The report describes in some detail the provisions which should be included in federal legislation to convert Medicaid into a block grant. It then also describes what the state of Texas should do once it gets a block grant to provide more cost-effective services to its citizens. In short, the report provides a roadmap for making a Medicaid block grant work at both the federal and state levels of government and should be of interest to state policymakers in all fifty states.The full report is available online here, and the pdf version is available here. Next