Jim Capretta and Yuval Levin have a piece in yesterday’s WSJ arguing that the implementation of Obamacare is still uncertain, and suggesting states should not move to set up exchanges.
Their primary argument is that talk of inevitability of the law’s implementation is designed to force states to move ahead, and they are trying to provide a political counterweight to that. They conclude:
President Obama won re-election and Democrats maintained control of the Senate this month, but the states hold the future of ObamaCare in their hands. Knowing the harm the law would do to their citizens, to the economy and to American health care, governors should refuse to become its enablers.
In public policy, the counter factual (as compared to what) is the most important thing to allow one to evaluate a choice. If not Obamacare, then what? Jim and Yuval provide the following:
Instead of following the Obama administration’s plan, states should seek real reform. For example, they should demand that Washington transform the federal portion of Medicaid for non-disabled and non-elderly beneficiaries into a uniform block grant, with state discretion over eligibility and benefits. The goal should be to turn Medicaid into a premium-assistance program rather than government-run insurance. Medicaid could then be used to help people enroll in mainstream insurance plans. This is the way to help the low-income uninsured get the same kind of coverage as other Americans.
I think this is a reasonable idea in the context of implementing exchanges and later moving in this direction. In my book I suggest federalizing the cost of the dual eligible portion of Medicaid and moving over time to buy low income persons into private insurance via premium support, after the exchanges are up and running. We don’t use the exact same language in describing our proposals, but there is some convergence of policy interests, if not political understanding (I understand this to be a follow on step to implementing Obamacare exchanges, they say you have to get rid of the first do this, which really makes no sense to me).
Both Jim and Yuval have written fairly comprehensive visions of what a replacement of Obamacare would look like, and a proposal for Medicare reform, respectively, so they have ideas. What they lack are members of the House of Representatives (that Republicans have controlled for 22 months and will continue to do so next Congress) who are willing to commit to the myriad details necessary to begin to transform these ideas into reality.
Imagine if at sometime during the past 22 months the House Commerce committee had marked up and reported out a bill to do what they describe above on Medicaid reform? Or marked up the Patients’ Choice Act that has been around for over 4 years so we could see what the CBO thinks about the relative impact of a weak individual mandate versus auto-enroll procedures for risk pooling? And they could say we hate the exchange regulations in the ACA, here is how we would do it? Then a far more concrete negotiation about next health reform steps would be possible.
It is easy to write a paragraph in an op-ed. It is very hard to write a bill that can withstand the bright light scrutiny that such a proposal would entail. Some Conservative critics of Obamacare have some decent ideas, they just don’t seem to have politicians committed enough to push for them via the legislative process.
similar post cross posted at freeforall