Friday, November 19, 2010

Is "compete and succeed" better than "repeal and replace"?

Senator Scott Brown (R-MA) thinks so. So does Senator Ron Wyden (D-OR). And Bernie Sanders (I-VT).

Senators Brown, Wyden and Sanders have introduced the "Empowering States to Innovate Act." Ezra Klein blogs that the Senators may have found a way forward on health reform.

"If a state can think of a plan that covers as many people, with as comprehensive insurance, at as low a cost, without adding to the deficit, the state can get the money the federal government would've given it for health-care reform but be freed from the individual mandate, the exchanges, the insurance requirements, the subsidy scheme and pretty much everything else in the bill," Ezra Klein writes. "If conservative solutions are more efficient, that will be clear when their beneficiaries save money. If liberal ideas really work better, it's time we found out. Forget repeal and replace, or even reform and replace. How about compete and succeed?"

The Wonk Room reports that Wyden, Brown, Sanders, who co-sponsored the original innovative waivers amendment, believe that their home states of Oregon, Massachusetts, and Vermont are leading the pack in adopting innovative approaches. These include the well-known Massachusetts program that Brown voted for as a state legislator, and single payer bills that have been introduced in Vermont and Oregon. The bill, though, also could appeal to states seeking a more conservative, less regulatory solution, since they would be able to decide how they wanted to provide comprehensive coverage to the uninsured, free of most of the ACA's mandates.

ACP's own proposal to provide all Americans with access to affordable coverage, initially developed in 2002 and revised by the Board of Regents in 2008, supports a similar state option. The very first recommendation in that paper supports:

"Giving states the ability to opt out of any national framework for universal coverage by establishing their own programs for expanded coverage and to redesign health care delivery and financing to emphasize prevention, care coordination, quality, and use of health information technology through the Patient-Centered Medical Home (PCMH), subject to federal guidelines and standards. States should be required to show that they can achieve enrollment in state approved coverage (private health plans or public programs) that is at least equal to the coverage that would occur without a waiver, taking into account the number of insured individuals, covered benefits, access to participating health care providers, and costs to the consumer."

There are reasons to be skeptical that the Wyden-Brown-Sanders bill will defuse the political confrontation over health reform. Republicans have vowed to "repeal and replace" the Affordable Care Act. It is unlikely that most will now buy into the idea that all Americans should have access to affordable and comprehensive coverage, but with states given more flexibility to come up with their own ideas on how to achieve this goal. States couldn't propose something that would result in fewer people having affordable coverage than under the ACA's mandates and subsidies.

President Obama and congressional Democrats can be expected to be extremely wary that the Wyden-Brown-Sanders approach could be a Trojan Horse that would lead to erosion of the ACA's consumer protections over insurance companies and guarantees of near-universal coverage.

Still, the idea of state innovation and experimentation makes enormous intuitive political and policy sense, especially given the fact that many GOP-controlled states are resisting the ACA's mandate and prefer a less heavy-hand, market-based approach. Liberals have always wanted the chance to implement a single payer plan on the state level, if not possible to achieve on a national scale.

The ACA won't be replaced and repealed by the 112th Congress, but its effective implementation could be weakened. As I wrote in this blog a few days ago, "There is another option than for both parties to engage in a no-win fight over repeal. They could look for ways to make improvements that preserve the key elements of the ACA - including the promise to provide coverage to most Americans - but allow for testing by states of free-market approaches to delivering such coverage." I would now add that Senators Wyden, Brown, and Sanders have an even better idea, which is to allow for testing by states of free-market approaches and more regulatory public options (including single payer) to delivering such coverage.

Today's question: Would you support allowing states to "compete and succeed" in designing plans to provide affordable coverage to all instead of "repeal or replace" or maintaining the ACA as it is?

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