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A Health Reform Framework: Breaking Out Of The Medicaid Model


July 10th, 2014

Editor’s note: This post is coauthored by Joseph Antos and James Capretta.

A primary aim of the Patient Protection and Affordable Care Act (ACA) is to expand insurance coverage, especially among households with lower incomes. The Congressional Budget Office (CBO) projects that about one-third of the additional insurance coverage expected to occur because of the law will come from expansion of the existing, unreformed Medicaid program. The rest of the coverage expansion will come from enrolling millions of people into subsidized insurance offerings on the ACA exchanges — offerings that have strong similarities to Medicaid insurance.

Unfortunately, ample evidence demonstrates that this kind of insurance model leaves the poor and lower-income households with inadequate access to health care. The networks of physicians and hospitals willing to serve large numbers of Medicaid patients have been very constrained for many years, meaning access problems will only worsen when more people enroll and begin using the same overburdened networks of clinics and physician practices.

It does not have to be this way. It is possible to expand insurance coverage for the poor and lower-income households without reliance on the flawed Medicaid insurance model. Opponents of the ACA should embrace plans to replace the current law with reforms that would give the poor real choices among a variety of competing insurance offerings, including the same insurance plans that middle-class families enroll in today. Specifically, we propose a three-part plan that includes a flexible, uniform tax credit for all those who lack employer-based coverage; deregulation of Medicaid; and improved safety-net primary and preventive care.

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A Senate GOP Health Reform Proposal: The Burr-Coburn-Hatch Plan


February 12th, 2014

Republican Senators Richard Burr, Tom Coburn, and Orrin Hatch recently released a blueprint for repealing and replacing Obamacare, called the Patient Choice, Affordability, Responsibility, and Empowerment Act, or the Patient CARE Act (PCA). The plan is getting significant attention from supporters and critics alike (including the editorial page of the New York Times) because both sides recognize that it is a serious effort to address the problems in U.S. health care in a manner that is strikingly different from Obamacare. The debate over the merits (or perceived drawbacks) of the PCA proposal was given further impetus by an assessment of its coverage and cost implications from the Center for Health and Economy (H&E), a new think tank headed by former Congressional Budget Office Director Doug Holtz-Eakin (and with a board including several other academics, including Uwe Reinhardt of Princeton University) and devoted to providing independent analytical assessments of major public policy initiatives.

In this short post, we describe the major provisions of the PCA, as we understand them from the descriptive material and conversations with the authors’ staffs. We also offer our views on how to think about the budgetary and coverage implications of the PCA proposal in the context of the estimates produced by H&E.

Major Provisions of the Patient CARE Act (PCA)

Repeal of Obamacare. The starting point for the PCA is repeal of Obamacare in its entirety, with the exception of the law’s Medicare provisions. We do not take the retention of the Medicare provisions from Obamacare as an endorsement of them by the authors. That would be inconsistent with the public record. For instance, Senator Coburn has proposed sweeping reforms of Medicare that differ substantially from the Obamacare Medicare provisions. The retention of the Obamacare Medicare provisions would seem instead to be an acknowledgement that it will be difficult enough politically to enact a sensible reform of the insurance market for the under age-65 population without also having to pass in the same legislation a comprehensive reform of Medicare. A reworking of Medicare is badly needed, of course, but it can be addressed on a separate legislative track from an Obamacare replacement plan.

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After The Fall (Off The Fiscal Cliff)


November 15th, 2012

Republicans were handed a convincing defeat at the polls, not only losing the race for the presidency but also losing ground in the Senate. The good news for the country is that Republican leadership is not in denial. The day after the election, Speaker of the House John Boehner outlined a balanced approach for easing federal policy off the fiscal cliff. He offered a combination of revenue increases and spending cuts, with an emphasis on “real changes to the structure of entitlement programs.”

Two days later, President Barack Obama responded by offering his own balanced approach—more federal spending, lower taxes for everyone but the wealthy, and the certainty of much higher budget deficits for years to come unless the savings proposed by the president last February actually materialize. This draws the line where it was before the election, with no sign that this will lead to meaningful policy negotiations.

This seeming recalcitrance is likely the result of the irrational exuberance that often strikes newly elected officials. To paraphrase Alan Greenspan, irrational exuberance has unduly escalated the president’s political asset value. Contrary to his current stance, President Obama does not have a strong hand in the upcoming fiscal debate. If he wants to avoid a double-dip recession and leave a positive legacy, he will have to accept compromises and sell them to his Democratic colleagues in the Senate. That inevitably means health policy, including the Affordable Care Act (ACA), will be on the negotiating table.

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After The Supreme Court, Higher Cost and Unrealistic Timeline Will Force Major Changes


July 2nd, 2012

The Supreme Court has spoken, but problems built into the Affordable Care Act (ACA) have not been resolved by the decision and may have worsened.  Even accepting the law’s assumptions about how the health system should be reformed, actually putting all the pieces in place is exceptionally expensive and difficult.  If President Obama wins a […]

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The Ryan Plan: The Cliffs Notes Version Of Republican Health Reform


March 21st, 2012

For the second year in a row, Rep. Paul Ryan (R-Wis.) has advanced a comprehensive budget plan that would restructure Medicare and Medicaid, repeal the big-spending portions of the Affordable Care Act (ACA), and ultimately resolve the fiscal crisis facing this country.  Critics react that the Ryan plan would dismantle health care as we know […]

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The Debt Ceiling Deal: Kicking The Can Down The Road


August 2nd, 2011

Editor’s Note: Below, Joseph Antos provides his take on Budget Control Act of 2011, which embodies the deal reached by President Obama and congressional leaders to increase the nation’s debt ceiling. See also Jonathan Oberlander’s post on the same topic. Congressional leaders and the President have come to agreement on a deal to increase the […]

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State of the Union: A Taste Of Budgets To Come


January 26th, 2011

Editor’s Note: Below, Joseph Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute, discusses President Obama’s State of the Union address. See other posts on this topic by Len Nichols and Kavita Patel.  In his State of the Union address, Barack Obama said the key to winning the future is […]

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Rethinking Health Reform: The Need For A More Incremental Approach


January 29th, 2010

Editor’s Note: In the aftermath of President Obama’s State of the Union address, what is the state of health reform? Where do we go from here? In the post below, Joseph Antos of the American Enterprise Institute addresses these questions. In other posts, Henry Aaron of the Brookings Institution and Timothy Jost of Washington and […]

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