On December 16, 2010 I wrote a post that began:

While the rhetoric around health reform has been incendiary from day one, in policy terms, a compromise between Democrats and Republicans using the outline of the Affordable Care Act (ACA) has always been available. The two primary problems with the health care system are costs and lack of coverage. The ACA does pretty well on the second, and is a start on the first, but much more is needed. It will be very hard to get a handle on health care costs, and we will likely only succeed in doing this if both parties are on board.

I then proposed the outlines of a deal:

  • Federally guaranteed catastrophic coverage implemented via Medicare
  • Private insurance sold in state-based exchanges for gap amounts if individuals desired more coverage, with income based subsidies
  • Federalizing the dual eligible Medicaid costs, and moving over time to buy low income persons into subsidized private gap insurance, thus transitioning the low income portion of Medicaid over time
  • ending the tax preference of employer paid health insurance; make all subsidies explicit

I refined these ideas in an e-book called Balancing the Budget is a Progressive Priority in August, 2011, and revised it after the failure of the Super Committee to replace the sequester in a version published by Springer in April, 2012. The book claimed that we didn’t need short term cuts in discretionary spending for a sustainable long run budget, but instead needed the next (and the next and so on) steps on health reform, and an increase in taxes collected as a percent of GDP to at least 21% given the movement of the Baby boomers into Medicare, Medicaid and Social Security.

There are many ‘yeah buts’ about the above-outlined deal. I am unsure what the ideal health system would be, because what I think what we most need is a political deal so that we can move ahead with the policy, focusing on the goals of expanding coverage and addressing costs. We will never do the hardest work asking whether health spending is ‘worth it?’ without both sides bearing responsibility for it.

So why do both sides need a deal?

  • For Liberals and Progressives, universal coverage is the holy grail, not just of health policy, but of all public policy. Conservatives don’t have a similarly focused top health policy interest, and that makes finding a deal more difficult (lengthy debate between myself and Jim Capretta touching on this). We need a deal because the continued Republican opposition to the ACA, which is made more effective by the Supreme Court’s decision making the Medicaid expansion voluntary, thwarts achievement of our goal of universal coverage (that I also believe to be a precursor to having a hope of addressing costs/wasteful spending).
  • Conservatives need a deal because they have no politically viable health reform plan embraced by elected Republicans, and without one they have no hope of what they claim to be their pre-eminent policy objective of smaller government, because the biggest long run spending side issue is health care costs. Keep in mind that Gov Romney ran on a platform of doing nothing to Medicare for 10 years (rescind House Budget cuts that mirrored the ACA; premium support starting in a decade). Further, the Republicans have controlled the House of Representatives for 28 months now, and have voted to repeal Obamacare numerous times, but never seem to get around to the replace part. Last month they couldn’t even muster the votes for a modest risk pool plan.

I obviously thought we needed a deal a long time ago, and my proposal to move away from Medicaid’s current structure has been the part of the ‘deal’ that has gotten me the most heat from my friends (here is a less grand deal). However, the discussion of the recent Medicaid study has reinforced my belief that the political warring over health reform crowds out our ability to make policy based on evidence. Every study is now just another salvo in a never ending political war around Obamacare, without the offer of a credible alternative. I am a strong supporter of the ACA which expands Medicaid, and would be happy to implement and revisit it when we know more. The passage of the ACA has put the entire health care system into play, and whatever final result we land on, its passage will have been the first step.

However, it is clear to me that both sides would benefit from a political deal to allow us to take the next steps with at least some of the heat removed from the conversation.

[Cross-posted at The Reality-based Community]

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Don Taylor is an associate professor of public policy at Duke University, where his teaching and research focuses on health policy.