The New Health Dialogue

It’s time for some straight talk about plans to “repeal” health care reform.

Republicans might engage in some budgetary maneuvers in an attempt to “defund” the health reform law but they are extremely unlikely to rollback enormously popular provisions such as the ban on pre-existing conditions exclusions or the small business tax credits.  They will, of course, push for many significant changes.  Democrats, however, know that they too will have to make changes. Health reform is and always will be a process, not a destination.

The legislation passed in March was one historic part of that process, but building a higher quality, lower cost health system will take at least a generation and will require everyone’s attention and effort.

As Kavita Patel, the director of New America's health policy program recently wrote for the Christian Science Monitor:

Health-care reform finally creates a level playing field where Americans will have access to health care that values quality of care, not quantity of care. It also puts into place much-needed regulations and limits on the private insurance industry. Patients will no longer be denied care simply because they had a preexisting condition. Patients who are not employed or have jobs that do not offer health insurance will not be left at the mercy of the individual health insurance market, where people purchase health insurance that does little more than provide catastrophic coverage. They will finally have choices that are affordable and easy to understand.

For the most part, the changes in legislation that the Republicans will propose will be quite different than those that the Democrats would support.  But the Affordable Care Act itself -- even if we didn’t move a single comma -- allows for a vast array of possibilities.  It was designed, in particular, to give broad leeway to states as they set up programs such as “exchanges,” the new markets for individuals and small businesses to access insurance coverage. 

For example, were conservative businesswoman and Republican gubernatorial candidate Meg Whitman actually holding the office she seeks, she might veto the legislation to set up the state’s insurance exchange, legislation that Gov. Schwarzenegger is likely to sign.  The Chamber of Commerce and the state’s largest insurer, Anthem Blue Cross, are lobbying heavily to kill the bill in part because it set up the exchange as an "active purchaser."

Under an "active purchaser" scenario, the exchanges will negotiate with insurers and will select which ones can offer coverage. These decisions will be influenced by a board which is subject to extremely strong conflict of interest provisions. No one who draws income from an insurer or provider will be allowed to serve on it.

Does this represent a federal government takeover of healthcare?  Far from it.  California is setting up its exchange in this way because it represent the will of the majority in this state.  Other states have the ability to set up vastly different markets more like what some have called "an insurance yellow pages."  In these cases, the exchange will basically be a website that simply presents information on a set of standardized products. (The plans in any state exchange, of course, will have to abide by certain new regulations and consumer protections in health reform, and low income people will get federal subsidies, no matter how the state decides to structure the exchange.)

States even have the option of not setting up an exchange at all. The irony there is if the state doesn't do it, the federal government will step in to set it up.  This must seem like a terrible Catch-22 to those people who believe that the law represents a government takeover of health.

It’s important to remember, though, how we got to this point.  The health insurance market was not working, in particular for people who buy insurance as individuals. These people were seeing costs skyrocket while their coverage withered away.

In almost every significant sense, the individual market was the “freest” market that we had for health insurance: consumer costs were not subsidized and they had the broadest range of choices. Along with being the "freest," it was the worst. One could argue that the solution is to further deregulate this market, but this is akin to helping Daniel by sharpening the claws of the lions in the den.  The question is not, therefore, whether we need reform and regulation, but what reform should look like and what the regulations should be. 

The good news is that there is a vast range of possibilities for how we implement health reform. But “repealing it” just isn’t one of them.  Moderates and conservatives can continue calling for repeal. Or they can constructively participate in shaping  implementation. We've got a long road ahead, and Americans would all benefit if we could figure out how to walk it together.