Avik Roy released a health reform proposal yesterday, published by the Manhattan Institute (full pdf). I am not going to go all post-modern literary critic on this (only deconstruct), in part because a lot of it lines up nicely with things I have been writing about/calling for over the past few years, in search of a political deal that could move the policy ahead. For example, I called for replacing the individual mandate and federalizing the dual eligibles and buying low income persons into exchanges in December of 2010! (these are “cousins” of what Avik proposes). My more fully fleshed out “next step health reform” version came in my book in 2011. Again, it is not hard to imagine a deal between what Avik and I wrote.

Perhaps most importantly is the tone, that acknowledges that policy deals are available. However, politics have been standing in the way.

As Avik puts it:

One of the fundamental flaws in the conservative approach to health care policy is that few—if any—Republican leaders have articulated a vision of what a market-oriented health care system would look like. Hence, Republican proposals on health reform have often been tactical and political—in opposition to whatever Democrats were pitching—instead of strategic and serious.

The biggest question facing Avik’s proposal is not in policy terms or what supporters of the ACA will think, but whether any elected Republicans will be willing and able to shift gears and begin trying to move health reform ahead instead of simply looking for what helps in the next election. My hope (and cautious expectation) is that the answer is yes, after the 2014 election.

Two things I especially want to encourage in reform discussions that overlap with what Avik has proposed and that I have previously proposed as part of a North Carolina-specific reform/waiver approach within the ACA (p. 6-7):

  • Imagine a Medicaid waiver in which the cost of the dual eligible beneficiaries (those covered by Medicare and Medicaid) are federalized to reduce the perverse incentives inherent with two payers of care; state cost savings could be used to expand insurance coverage

  • Pilot a premium support approach to the setting of premiums for Medicare advantage plans in North Carolina, two to three years after we begin a State-run insurance exchange with the Medicaid waiver/BHP expansion I suggest

There is lots of health policy to be banged out in those two points that I have suggested, but the need for LTC reform is a crucial issue that I have written much about. And the current political stalemate in which exchanges are the panacea in the Medicare program, and the worst thing ever in the ACA–and vice versa, is silly.

I will have more detailed comments later, but I commend Avik for offering this plan, and think there is a plenty to like in the proposal itself, as we look for the next step in health reform.

[Cross-posted at The Reality-Based Community]

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Don Taylor

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