Everything seems to be pointing toward two years of partisan and ideological confrontations over health reform. The leadership of an emboldened Republican party has made it clear that it will use its newfound House majority to seek to "repeal and replace" the Affordable Care Act (ACA), and if that doesn't work, to "defund" it. Huge GOP gains in statehouses make it likely that more states will resist implementation. Meanwhile, President Obama has stated that he is open to "tweaking" the law but not "re-litigating" the health reform debate.
This is a debate that neither side is likely to win.
Let's start with the Republicans. They believe that they have a mandate to seek repeal of the ACA, but they won't be able to deliver. The House GOP will run smack dab into a Senate that will do what the Senate does best, which is to bury legislation that comes out of the House. Senate Democrats will use their majority - and the filibuster, if needed - to block efforts by the House to repeal or reverse key provisions, and President Obama will use his veto pen if necessary.
Plus, when it comes to specific changes, the GOP may find that they don’t have the public's support. Do voters really want the new Congress to repeal the prohibitions against insurance companies charging more to people with pre-existing conditions? Do they want to give up their "free" preventive services and annual Medicare wellness exam? Will they want to give up the promise made by the law that if they lose their jobs starting in 2014, they won't lose their health benefits?
What about physicians? Do they really want Congress to take away the 10% increase in Medicare payments for primary care to be in effect for the next five years? Do they want Congress to withdraw funding to raise Medicaid primary care payments to the Medicare rates? Do physicians want Congress to defund programs intended to reverse a growing shortage of primary care physicians? Do they want Congress to halt the redistribution of unused residency positions to general internal medicine and family medicine residency programs? Do they want Congress to stop the federal government from enforcing rules to require insurance companies to standardize, simplify and reduce paperwork on physicians and patients?
What about the programs created to lower costs and improve outcomes? Will the new GOP House, which has complained that the Affordable Care Act doesn’t do enough to control costs, want to eliminate funding for comparative effectiveness research and the new Center on Medicare and Medicaid Innovation - two of the most promising avenues to lower costs and improve outcomes? And if the GOP were to repeal the savings in Medicare from reducing payments to hospitals and Medicare Advantage plans without finding offsets, the result would be a whopping $500 billion increase in the budget deficit, according to the CBO.
By committing itself to a "repeal and replace" agenda, the GOP risks alienating many voters for trying to dismantle popular parts of the law, disappointing its base for failing to get rid of it, and upending its promise of deficit reduction.
This doesn't mean that President Obama or the Democrats necessarily will have the upper-hand. The fact is that the President has been unable to persuade a huge chunk of the electorate that the Affordable Care Act will make health care more affordable. Instead, many believe it will lead to higher premiums, more government spending, and more debt. As long as this is so, the Affordable Care Act will continue to be politically vulnerable, and many Democrats who support it will continue to be at electoral risk.
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.
They could start by allowing states a great deal of flexibility in setting up the health exchanges. The Washington Post reported on Tuesday that with GOP gains at the state level, "two models are likely to appear: Democratic governors and legislatures are likely to emphasize vigorous regulation and government oversight, while Republican state leaders are likely to put greater stock in privatization and other free-market approaches." States could experiment, for example, by offering health savings accounts on an equal playing field with other insurance products. HHS Secretary Sebelius has already signaled a willingness to consider states' requests for waivers from certain ACA requirements.
President Obama and Congress could also agree to expand upon and accelerate the authority granted by the ACA to allow insurance to be sold across state lines. They could agree to a serious effort to make real reforms in the medical liability system, such as authorizing and funding a national demonstration project of health courts. They could even commit to a bipartisan effort to reform Medicaid to make it a more effective and affordable program. And while they are at it, they could get a bipartisan deal on reforming physician payments and repealing the Medicare SGR.
For all of this to happen, though the GOP would need to back down from repeal being the only acceptable option and accept the law's commitment to provide most Americans with affordable coverage. President Obama and his congressional allies would have to be willing to give the states more options to implement market-based reforms, to recognize that not every program created by the ACA is of equal importance for funding, and to show courage in making medical liability reform a priority.
The political dynamics are such that none of this is likely to happen, but I think the country would be better off if they tried.
Today's question: Do you think President Obama and the GOP can agree on improvements to the ACA, or is the polarized debate on "repeal and replace" our inevitable future?