A central claim of my book Balancing the Budget is a Progressive Priority is that slowing the rate of health care cost inflation is a necessary, but not a sufficient condition to our ever achieving a sustainable budget down the road (it will also take a tax increase). Further, it will be virtually impossible to take the very hard steps to address health care cost inflation without both political parties coming up with a set of health care reform strategies that we will actually try, and which make both sides responsible for seeing to the hard work this will take. Health reform is far more difficult than Social Security reform (in a technical sense), for example, because mailing checks is much easier than purchasing health care. We will never be done with health reform and there will be many mid course corrections.
Even though we don’t know what all the steps will be, we desperately need to take some initial ones, and we will soon know what the Supreme Court will say about the ACA. This will be a landmark decision that will have profound political and policy consequences, but in one sense, regardless of what the Supremes say, the next step is to identify a bipartisan way forward on health reform (stop laughing; we have to do it).
Central to my book is a set of health reform policies that I claim represent the type of deal that would emerge if the two sides actually negotiated with one another. For such a deal to emerge, it would take both sides being clear about what their primary interest was in health policy. For Progressives, universal coverage has always been the holy grail and dream deferred, not just of health policy, but really of all social policy. As I noted in this debate with Jim Capretta, I don’t think Conservatives have an interest that is so clear and heartfelt as universal coverage is for Progressives, but if I had to take a stab, I would claim that it is their belief that people don’t have enough “skin in the game.” As an aside, this makes little sense to me, and when I look at empirical data on cost sharing with my more conservative friends, we see different things. In a similar way, when I say that I think the lack of a predictable, universal health insurance coverage scheme is an existential mark against our nation, they don’t get my degree of feeling.
Accepting such differences is an important step, because reaching a deal will mean abiding with one other to reach a compromise.
The essence of the deal I suggest in the book is this:
- Universal catastrophic coverage implemented through Medicare, with gap insurance available to persons wanting it (no mandate!) via state based exchanges
- With a massive deductible (I suggest $10,000/persons; $15,000/family to maintain a key role for private insurance; far larger out of pocket exposure than Bronze level cover in the ACA)
There are many legitimate ‘yeah buts’ that both sides will have, and I am not even getting into the other parts of the health policy deal I propose, and that are detailed in the book, in this post. However, a compromise health reform deal will have to capture the ‘big idea’ for both sides. I think step one of such a deal will look something like this if we ever manage to do it. And if we don’t, we will never again have a sustainable budget.