Reinsurance, expanding coverage and the search for a deal

Slammed with project deadlines so light on the blogging….but wanted to point to Reihan Salam’s interesting and useful post about different approaches to reinsurance/federal guarantees to help move toward universal coverage. He points out that there are a fair number of liberal/progressive types who have embraced models of trying to get universal, catastrophic coverage with various mixes of public and private payers. Such a proposal is central to my book. Further, here is a series I did on the federal flood insurance program, that highlights some potential lessons and/or the usefulness of this model to inform the possible use of federal reinsurance/backstopping of some sort.

I see lots of issues in Obamacare that could be improved and addressed within the parameters of the law, and there are lots of alternatives and ideas. I especially want to highlight Reihan’s highlight of Gene Steuerle’s critique of the ACA and of Republican critiques of the law as well. Federalizing the dual eligibles and moving over time to buying low income persons into private insurance is a worthy goal on many fronts,and would remove one of the “tranches” as Gene calls them.

There is some convergence from right and left on key issues if you focus on the policy, and if we can at least start from a goal of providing everyone with some level of predictable coverage. The stumble is the politics….we have to figure that out. By that I mean I am open to and even prefer large changes to Obamacare as should be clear from my book. However, these steps need to be negotiated and enacted from the basis of the existing law. I just don’t see how it is politically feasible for the first step to be a repeal of Obamacare without clarity of what comes in its place.

The next step is the election. Somehow we have to get to the point after that where good policy also becomes good politics.

update: revised wording.

The Conservative case for the ACA

is the title of an op-ed in the New York Times by J.D. Kleinke of the American Enterprise Institute. If you have read my blogging or my book, you will know that I basically agree with him–the political rhetoric around Obamacare never matched the policy reality.

Some predictable push back from Capretta, and Cannon. I like both of these guys personally, and think they have some good thoughts and ideas. However, the opposition to Obamacare, driven in part by them, has always been oversold on policy terms and has been mostly about politics. What would be useful would be for them to be clearer about what they would do instead. In fairness, Jim Capretta has written a fairly complete vision of what a replace of Obamacare would look like, and Michael and colleagues at Cato have an ebook on reform options.

The biggest problem with their replace plans is the lack of 218 members of the House and 60 in the Senate that will vote for their ideas after voting to repeal Obamacare, presumably after a Republican clean sweep this fall. If the President wins re-election and the hope of repeal becomes a fantasy, I think there will be a deal to move ahead on health reform, wrapped up in an overall deal on the tax code, etc. in the next Congress. My book gives my version of such a deal. Here is the big idea of my proposed deal.

update: fixed a link.

Health reform and the election

Greg Sargent noting that in spite of the Affordable Care Act not being overly popular as a whole, focus on health reform during the election could be helpful to the President.

I would agree and go even a bit further, and say that avoiding health reform discussion since passage of the law has enabled Republicans to get away with only being clear about what they are against, and let them off the hook from offering a coherent alternative. The more discussion about health reform during the election the better. If Republicans move toward a plan that attempts to substantially address coverage, cost and quality, it will start to look an awful lot like what they have been against. If they don’t offer a comprehensive plan, then they will have no answer to one of the key issues facing our country.

The Affordable Care Act was a good step because it was a step; we desperately need to take the next one and find some set of health reform policies that we will actually TRY. It will take both sides to do this, and an important step is to smoke Republicans out on what they are really for (if anything). This is a time where the Rove playbook–go on offense around a presumed weakness–should be co-opted by the President, both for policy and political reasons.