This op-ed by Gov. Mitch Daniels includes an introductory critique of the Affordable Care Act that's so overstated that it borders on comedy.
(I mean, "all claims made for it were false"? Really? Every single one?) But once you get past that, it's exactly what I've been hoping to see from a major member of the Republican Party: It's a list of changes that Congress could make to the Affordable Care Act in order to make it acceptable to Republicans, or at least to Mitch Daniels.
• We are given the flexibility to decide which insurers are permitted to offer their products.
• All the law's expensive benefit mandates are waived, so that our citizens aren't forced to buy benefits they don't need and have a range of choice that includes more affordable plans.
• The law's provisions discriminating against consumer-driven plans, such as health savings accounts, are waived.
• We are given the freedom to move Medicaid beneficiaries into the exchange, or to utilize new approaches to the traditional program, instead of herding hundreds of thousands more people into today's broken Medicaid system.
• Our state is reimbursed the true, full cost of the administrative burden to be imposed upon us, based on the estimate of an auditor independent of HHS.
• A trustworthy projection is commissioned, by a research organization independent of the department, of how many people are likely to wind up in the exchange, given the large incentives for employers to save money by off-loading their workers.
According to Daniels, these changes would transform the program from an "impending disaster" into a system where "customer choice would be dramatically enhanced" and "health care would be much more affordable."
I don't agree on the impending disaster part, but the rest of it is true, though with a few big catches: There'd be more choices because there'd be fewer standards, and there'd be cheaper coverage options because insurers would be allowed to offer extremely limited products.
Most of the list is composed of small tweaks. Daniels doesn't think the bill sufficiently reimburses the states for administrative costs, or worries the legislation is insufficiently welcoming to high-deductible plans, or wants another estimate of take-up in the exchanges? Fair enough. Those concerns should be addressed.
The bigger-ticket items are Medicaid and the mandates. I don't see anything wrong with allowing states to move Medicaid-eligible populations into the exchanges -- at least so long as they're committed to giving them access to high-quality insurance once they're in there (remember, Medicaid is much cheaper than equivalent private insurance products). This is actually a compromise I mentioned explicitly in my piece envisioning the health-care system in 2030.
But I wonder what Daniels really means when he calls for "all the law's expensive benefit mandates [to be] waived." Does he mean the categories of care that the bill directs insurers to cover? Does he mean that the bill should throw out protections from preexisting conditions and limits on annual caps? I'm on the side of more, not less, flexibility in this area, but that's not the same as getting rid of standards entirely.
That said, this is a worthwhile debate to be having. Whether the law excludes innovative insurance products that could help bend the cost curve is a much more productive debate to be having than whether we should be making a major move to cover our citizens and bend the cost curve at all. And there's no doubt that the legislation's actual implementation would benefit from the buy-in of conservative governors like Mitch Daniels.
Daniels, of course, doesn't have a vote in Congress, and it's not even clear he has many friends there. But I wouldn't be too quick to dismiss the deals he offers. Back in September, Daniels called for a second stimulus centered around a payroll tax cut and full expensing for business and investment. Both were part of the deal that congressional Republicans struck with the administration a few months later.
Ezra Klein Washington Post
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