The field of health policy and management HPAM faces a gap between theory, policy and practice. Despite decades of efforts at reforming health policy and health care systems, prominent analysts state that the health system is “stuck” and that models for change remain “aspirational.” We discuss four reasons for the failure of current ideas and models for redesigning health care: 1 the dominance of microeconomic thinking; 2 the lack of comparative studies of health care organizations and the limits of health management theory in recognizing the importance of local contexts; 3 the separation of HPAM from the rank and file of health care, particularly physicians; and 4 the failure to expose medical students to issues of HPAM. We conclude with suggestions for rethinking how the field of HPAM might generate more promising policies for health care providers and managers by abandoning the illusion of context-free theories and, instead, seeking to facilitate the processes by which organizations can learn to improve their own performance.
Well, there’s a way for congressional Republicans to go after Obamacare, cronyism, and the Democrats’ assertion that the GOP is in league with health insurers, all at once: by repealing Obamacare’s risk-corridor bailout. And after overcoming some internal resistance from don’t-rock-the-corporate-boat Beltway Republicans, it looks as if the House GOP is going to move in this direction. If they do—and if they were also to refuse to reauthorize the Export-Import Bank and were to move to reverse President Obama’s failed amnesty policies—Republicans could legitimately make the case this fall that they stand with Main Street America.
Obamacare’s risk-corridor program is a way of shifting risk from insurance companies to taxpayers—of putting the latter on the hook if the former lose money. The risk corridors’ existence incentivizes insurers to lowball their prices, since they know taxpayers will help cover their losses. It’s bad policy, and it’s unpopular. Recent polling by McLaughlin & Associates, commissioned by the 2017 Project, asked, “If private insurance companies lose money selling health insurance under Obamacare, should taxpayers help cover their losses?” Only 10 percent of respondents said yes; 81 percent said no. Yet, absent congressional action, that is exactly what’s poised to happen.
Over the past four years, oceans of ink, tons of sweat and doubtless a few tears have been spilled by smart people — including yours truly — in the noble quest to devise an ideal plan to replace Obamacare with a patient-centered health care system. And while sensible proposals abound, most are currently going nowhere, either because they’re too complicated or because they gore a few too many special-interest oxes.
Health care reform is hard because everyone has a stake in it and no one wants to be the unintended victim of a national experiment. But reform doesn’t have to be hard. All we really need is three simple tweaks: 1. Let individuals and employers opt out of Obamacare; 2. Let seniors opt of out of Medicare; 3. Let everyone have an Health Savings Account.
That’s it. While this three-point plan is by no means a silver bullet for all that ails our beleaguered American health care system, it would plant potent seeds of freedom amidst the thorny brambles of government-run health care. And the beautiful thing, politically, is it’s easy to explain and hard to oppose.
The Affordable Care Act is the worst piece of legislation ever passed into law in the United States. It was poorly conceived, poorly written, poorly enacted, and is being poorly implemented. The thing is a mess. However, it does open up some doors that were firmly locked before—things that most free-market economists have been espousing for years without success. We should not run away from those things just because they have President Obama’s name on it.I am not talking about the things the idiot media think are popular—the slacker mandate, open enrollment, equal premiums for men and women, and free “preventative” services. These are all terrible ideas for reasons I won’t go into here unless you insist.I’m talking specifically about several more important elements of the law that were not well crafted in this particular bill, but can now be used as precedents for major improvements in American health care.
For all of the non-stop wall-to-wall coverage of yesterday’s Supreme Court decision in Burwell v. Hobby Lobby—in which the Court ruled that the government doesn’t have the authority to force “closely-held corporations” to violate their religious beliefs—a simple fact has been lost. The ruling did not overturn a single word of the “Affordable Care Act,” otherwise known as Obamacare. Nor did the Supreme Court prevent the government from requiring that taxpayers finance abortion-related services.Pro-life activists—and Obamacare opponents—are cheering today. But when they sit down and reflect, they’ll realize that they haven’t won a thing.
Holiday weekend changes to the health care law have become commonplace. Despite repeated insistence that the law was working, the administration chose Thanksgiving to announce its delay of enrollment for the small business exchange. Also over the Thanksgiving week, the administration announced that open enrollment for 2015 would not begin until November 15, 2014. And even Christmas was not off limits as the administration pushed back the deadline to enroll for coverage starting on January 1. Of course, on New Year’s Eve, then-Health and Human Services Secretary Kathleen Sebelius declared there would be no more delays, just another promise that has not held true.
For the past couple of months, the law’s supporters have toasted to success on more than one occasion, ignoring the fact that the backend of the exchanges have yet to be built, millions of ‘inconsistencies’ remain unresolved, and several state exchanges remain in disarray. We can only imagine what could be next.
It is not possible to displace Obamacare without advancing a credible alternative. Simply repealing the law implies a reversion to the pre-Obamacare status quo, which had its own set of problems. To repair American health care, critics of the president’s plan must offer reforms that address the defects of the old system while jettisoning Obamacare’s fatal combination of soaring costs and shrinking access to doctors and leading hospitals. Doing so would win broad public support. In polling done for the 2017 Project, a group advancing a conservative reform agenda, the public favored replacing Obamacare 44 percent with an alternative, as opposed to keeping and fixing it 32 percent.
Of course, the Republicans’ language is unlikely to become law, thanks to the Democrats’ fervent fidelity to their hard-won health care handiwork. But the debate over a delay should, if anything, help the GOP heading into this year’s midterm elections. The party is already expected to do well. Simply by focusing its fire on the mandate, the GOP can refocus the larger health care debate around it, and thus elevate its importance in the campaign.That’s smart politics. Health care is now firmly at the top of voter’s minds, according to research by The Polling Company for FreedomWorks. Full disclosure: I helped conduct this research. Voters usually name “health care” as one of their “top 10” issues. But right now it’s one of the “top three,” along with “jobs / economy” and “government spending.” An unpublished January poll by Heart-Mind Strategies for the Heritage Foundation is even more striking, finding health care to be in the “top one” – that’s right, the No. 1 issue on voters’ minds.It gets better. The Polling Company research finds a solid majority of voters in every category – including the law’s supporters – support a delay of the whole law, not just the mandate. Sixty percent say they favor a delay “to make sure the law is fair and workable for everyone.”
The best part of the plan is the fixed tax credit. This is an idea proposed by Mark Pauly and me in Health Affairs almost 20 years ago and virtually all economists favor it. It contrasts with tax deductions and exclusions employer payments that are not counted in the employee’s taxable income. These unbounded tax subsidies encourage over-insurance because we can all lower our taxes by buying more expensive insurance. The fixed sum tax credit, by contrast, pays for the first dollars of coverage but beyond some point all remaining premium payments are made with after-tax dollars. This means that individuals won’t buy another dollar of insurance unless they get a dollar’s worth of value.Another good feature of the Capretta plan is that the tax credit is independent of income. It is universal, at least for people who buy insurance on their own. This contrasts with the Burr/Coburn/Hatch proposal, with which Capretta is associated and which he curiously promotes in the same chapter where he describes his own plan – even implying that the two plans are essentially the same. They’re not.
Savvy primary voters understood that all GOP candidates would criticize the detested Obamacare law, but they were looking for candidates committed to actually working towards repealing and replacing it. The Repeal Pledge was established in the summer of 2010 for just that purpose. It is designed to attest to the seriousness of the signer’s understanding that the Affordable Care Act is so fundamentally and structurally flawed that it cannot be fixed. Instead, it needs to be delayed, defunded, and prevented from metastasizing until it can be repealed and replaced with positive, patient-centered reforms.