My book at the ACA

A few folks writing me about my book and whether I support the Affordable Care Act after yesterday’s post, and a question about the cost of what I proposed in my book.

  • Yes, I am a strong supporter of the ACA. The book makes my support quite clear. However, even if all goes well, it is not the last word. A policy based health reform would likely mean revisiting/tweaking/adding things to the ACA/our health system every Congress for the rest of my life. We will never be done with health reform. Here are the ~30 columns on health reform I wrote for the News and Observer from June 2009 to May 2012.
  • I don’t think we will ever do the hardest parts of addressing costs without both political parties bearing responsibility for the effort. To date, Republicans have been the ones who are only clear about what they are against, with no coherence about what they are for. Maybe that is changing, but they are the “side” without a clear negotiating position, at least among elected officials. Their offer is the next step to get to a broader deal that I believe to eventually be inevitable.
  • One person asked if I was claiming that ending the tax exclusion of employer provided health insurance would pay for everything I wrote in my book in terms of health policy. Short answer is no. Fuller answer is that my book is really a set of ideas about the direction that I think we would go if Republicans and Democrats actually negotiated what I understand to be their ideological/interest group interests on health reform. My book offers a set of directions and ideas as opposed to costed-out plan, and they are big changes I suggest.
  • For example, if we had a universal federally guaranteed catastrophic insurance plan (lets say Medicare part E), the cost of covering the young uninsured with a huge deductible like I suggested ($10,000) would be relatively inexpensive. However, if everyone is covered by such a catastrophic plan, you could expect that employers would alter private coverage to ‘wrap around’ the catastrophic amount. This would result in several things happening over time. (1) the link between employment and health insurance would break down. A huge change that I think would be a good one, as it would actually allow entrepeneurs to innovate and take risks; today there is a Duke employee(s) with a great idea for a business but who remains locked into a job they don’t like simply for the health insurance. (2) Less employer sponsored health insurance would shift compensation from the non-taxable vareity (health insurance) to the taxable variety. (3) I would want to offer private gap insurance in exchanges, with coverage eventually bought with after tax dollars, and therefore remove the hidden subsidy of health insurance via the tax code, and make any income-based (my preference) subsidy be totally transparent. Costing this out is beyond my technical expertise….what I was trying to do is give a sense of where I think we should head next. I think a deal of some sort (whether mine or otherwise) is eventually inevitable, but not sure when. Until then, I am all for implementing the ACA.
  • Even if there were a resurgence (or I would say a beginning) of serious conservative proposals on health policy put forth by elected officials, the first step to this outcome will have been the ACA. It broke the logjam that was the status quo.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

4 Responses to My book at the ACA

  1. richard says:

    “I would want to offer private gap insurance in exchanges”. I agree with catastrophic coverage but in terms of providing support in the vicinity of the deductible wouldn’t it be more efficient to simply provide deductible support, like a health savings account though not necessarily tax advantaged. This I think would have a transformative effect especially when you look at PCP. I am always struck at what should be a simple enterprise is very complex. This may be geographically biased but when i see my physician or my child’s pediatrician there is an army of administrative personnel dedicated to chasing down reimbursements. If the PCP was cash driven their overhead would be significantly lower and you could see it being much more lucrative than it currently is. Imagine a world where a PCP charges $40 per visit and averages 4 visits an hour. If he is getting the money from the patient at the time of service realistically he could manage on a staff of one or even none. More and better compensated PCPs equals fewer specialists, fewer unnecessary procedures and probably better coordinated care. Anyways, my two cents. Have you read David Goldhill’s book? I would be interested in your thoughts on it.

    • Don Taylor says:

      I haven’t read Goldhill’s book, but will try and take a look. Family issues have been predominating as we are navigating a transition of my mother in law from a NH to assisted living. There are lots of different catastrophic approaches, and I would likely consider most of the friendly amendments….I mostly want to get true universal cata coverage and move away from tax preferenced spending.

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